2011 RQHR Venous Thromboembolism Prophylaxis Audit : Data Collection Form
Patient Code (patient initials and MRN): ______
Audited by: ______Date: ______Ward: ______
Section A: Patient Groups Excluded from Audit (check all that apply)
Patient population excluded from audit:
q Palliative (followed by Palliative Care or CTC [compassionate terminal care])
q Psychiatric Care
q Rehab
q No acute medical conditions and awaiting placement in long-term care
q Age less than 18 years of age
q Expected length of stay <48 hrs AND patient is fully mobile
If you selected any of the above options do not complete the rest of the form.
Section B: Patients on Therapeutic Anticoagulation
Patient is on therapeutic anticoagulation:
q Unfractionated heparin (except heparin lock/flush)
q Low molecular weight heparin
(i.e. tinzaparin, enoxaparin, dalteparin)
q Warfarin (INR in therapeutic range) / q Oral anticoagulants (i.e. dabigatran, rivaroxaban, apixiban)
q Other ______
If you selected any of the above options do not complete the rest of the form.
Section C: Anticoagulant Thromboprophylaxis Provided
VTE Prophylaxis: Opt-Out Protocol
□ Tinzaparin 4 500 units subcutaneously once a day
No dose adjustment of tinzaparin is needed in patients with impaired renal function1, renal failure2,3, or on hemodialysis2,3
Prophylactic dose of tinzaparin if not 4 500 IU:
□ if weight < 50 kg tinzaparin 3 500 units subcutaneously once a day
□ if weight 100-150 kg tinzaparin 10 000 units subcutaneously once a day
□ if weight 151-200 kg tinzaparin 14 000 units subcutaneously once a day
Is this dose of tinzaparin appropriate for this patient □ Yes □ No (specify)______
□ Other (specify)______
If you selected any of the above options in Section C, proceed to Section G.
Section D: High Bleeding Risk or Contraindications to Anticoagulant Thromboprophylaxis (check all that apply)
q Heparin induced thrombocytopenia (fondaparinux not contraindicated)
q Severe thrombocytopenia
q Less than 12 hrs before anticipated spinal invasion, less than 2 hrs after spinal invasion or less than 18 hrs before anticipated epidural removal / q Active bleeding
q Recent intraocular or intracranial surgery
q Severe coagulopathy
q Hypersensitivity to heparins
q Recent major bleeding (specify) ______
q Other (specify)______
If you selected any of the above in Section D, proceed to Section E, otherwise proceed to Section F.
Section E: Mechanical VTE Prophylaxis for Patients at Risk of Bleeding
□ Bilateral graduated compression (antiembolic) stockings (TEDS)
□ Bilateral intermittent pneumatic compression (IPC)
Section F: VTE Risk - this section describes the risk factors in patients who are not receiving appropriate thromboprophylaxis (check all that apply)
¨ Active cancer or cancer treatment
¨ Admitted due to congestive heart failure
¨ Admitted due to severe respiratory disease
¨ Central venous catheter or PICC
¨ Collagen Vascular Disease
¨ Immobility
¨ Inflammatory bowel disease (history or current reason for admission)
¨ Inherited or acquired thrombophilic conditions
¨ Ischemic stroke / ¨ Lower extremity paralysis
¨ Major surgery
¨ Mechanical ventilation
¨ Nephrotic Syndrome
¨ Pregnancy/post-partum
¨ Previous VTE
¨ Sepsis
¨ Spinal cord injury
¨ Trauma
Section G: Appropriate Anticoagulant Thromboprophylaxis
Order for thromboprophylaxis was written ______hours after admission or after end of surgery:
□ 0-24 hrs
□ 24-48 hrs
□ >48 hrs
□ Thromboprophylaxis was continued for an appropriate duration
· In-hospital: □ duration of stay □ for ______days
· Orthopedic surgery: for ______days post-discharge
Section H: Patient Chart Documentation
Is there a preprinted order set that includes thromboprophylaxis in the chart?
q Yes If yes, is the thromboprophylaxis section of the OS: q blank q complete q other (specify):______
q No
Section I: Additional Comments (optional)
Summary:
1. Patient is at risk for VTE: □ Yes (all other patients)
□ No (as indicated in Section A or B above)
2. Patient received appropriate VTE prophylaxis: □ Yes
□ No If No, state reason: ______
1. Mahé O, et al.Thromb Haemost. 2007;97:581-6; 2. PROTECT Investigators. N Engl J Med. 2011;364:1305-14; 3. Nutescu EA, et al. Ann Pharmacother. 2009;43:1064-83.