Immobility confusion hampers thromboprophylaxis care

19 November 2008

MedWire News: Risk assessment for inpatient venous thromboembolism (VTE) is hindered by inconsistent definitions for immobility, show study findings that highlight the need for a universal term.

“This lack of a definition impedes the consistent use of deep vein thrombosis (DVT) prophylaxis,” write Knut Kröger and co-workers, from the University of Essen Medical School in Germany.

“Future studies on DVT prophylaxis in medical patients have to keep this in mind, otherwise their acceptance in and transfer to routine in patient care will be as difficult as they are for the current studies.”

To determine how immobility is evaluated in medical patients, the team asked the heads of 770 medical and 80 orthopedic departments to complete a questionnaire, 35% and 50% of whom replied, respectively.

The questionnaires revealed that just 19% of medical departments had obligatory rules for management of immobility compared with 48% of orthopedic departments, but that 90% and 98% of departments, respectively, classified immobility as a risk factor for VTE requiring thromboprophylaxis. thromboprophylaxis.

About half (53%) of orthopedic departments accepted “physical activity limited due to the disease” as an indication for thromboprophylaxis. However, the definition of immobility varied significantly more among medical departments, ranging from “completely bedridden” to patients who were out of bed for less than 2 hours a day.

Noting that the current American College of Chest Physicians guidelines recommend thromboprophylaxis for patients “confined to bed,” the team comments: “Whether patients who leave the bed for less than 1 h in the morning and 1 h in the afternoon are really at risk for thromboembolic events has never been prospectively investigated.”

Length of time also varied, with immobility an issue if occurring for more than a day in 53% of medical departments and 42% if more than 3 days, compared with 75% and 25% of orthopedic departments, respectively.

Immobility was documented daily in 46% of medical and 58% of orthopedic departments but the majority of records were completed by nursing staff, with just 25% and 11% of doctors reporting immobility.

“As lack of DVT prophylaxis leads to juristic claims (tendency increasing) the documentation of immobility as a relevant risk factor becomes more and more important,” Kröger et al observe, noting that many of the respondents were aware of this issue.

They conclude: “In general, it is important to document patients' immobility status, give clear recommendations on how to deal with risks arising from immobilization, and implement written instructions.”

Thromb Res 2008; 123: 251–257