outpatient lower limb immobilisation risk assessment tool audit

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Jung Yin Tsang Cezary Kocialkowski Abhijit Bhosale Anand Pillai

Title: Venous Thromboembolism Prevention for Patients in Lower Limb Casts: Development of

a New Risk Assessment Tool

Presenter: Jung Yin Tsang

My disclosure is in the Final AOFAS Mobile App.

I have no potential conflicts with this presentation.

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The risk of venous thromboembolism (VTE) is increased in transient lower limb immobilisation by a factor of 10.1

Depending on patient and cast, the incidence of VTE events for patients in plasters is 5-40%.2

In Europe, patients are prescribed routine prophylaxis for temporary lower limb immobilisation.

However, in the UK there is a lack of consensus, especially for outpatient treatment.

Current guidelines are unspecific and may result in overtreatment of low risk individuals

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NICE Guidelines (2010)2

All patients in lower limb casts should be risk assessed. If there is an increased risk of VTE, consider offering low molecular weight heparin (LMWH)

The College of Emergency Medicine Guidelines (2013)3

All patients in lower limb cast and one additional risk factor for developing VTE should be strongly considered for thromboprophylaxis

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A VTE risk assessment tool was developed based on guidelines and our experience with inpatient prophylaxis.

All patients with lower limb immobilisation that attended A&E or fracture clinic to from Jan-Mar 2014 were retrospectively identified from electronic case records and case notes.

Patients were scored on specific criteria including age, body mass index, mobility, hormonal risk, medical and trauma risk.

Only patients at high risk (Cumulative risk score ≥14) were prescribed extended prophylaxis of 40mg LMWH for the duration of cast immobilization.

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Type of Injury No. of Patients(%)

Ankle Fracture 27 (51%) Metatarsal Fracture 23 (43%) Tibial Fracture 2 (4%) Calcaneal Fracture 1 (2%) Total 53 (100%)

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Out of 53 patients, 31 were risk assessed and 12 patients were given thromboprophylaxis.

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There was 1 patient with risk score >14 whom was already taking warfarin and hence was not given prophylaxis

There were no cases of VTE in the cohort.

The VTE risk assessment tool rationalizes the need and use of prophylaxis by robustly targeting high risk patients.

It avoids needless anticoagulation in low risk individuals but yet ensures that the benefits and risks are considered.

Progress is needed to ensure all patients are risk assessed

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1. Scottish Intercollegiate Guidelines Network (SIGN). Prevention and management of venous thromboembolism. SIGN publication no. 122. Edinburgh: SIGN; 2010

2. National Institute for Health and Clinical Excellence (NICE). Venous thromboembolism: reducing the risk. CG92. London: NICE; 2010

3. Roberts C, Horner D, Coleman G, et al. Guidelines in Emergency Medicine Network (GEMNet): guideline for the use of thromboprophylaxis in ambulatory trauma patients requiring temporary limb immobilisation. Emerg Med J. 2013 ; 30(11):968-82

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