Safe prescribing of thromboprophylaxis post-TURP

Dr Hazel Chon, Dr Piranavan Kirupananthan, Mr Manish Gupta

Introduction

- Trans-urethral resection of the prostate (TURP) is one of the most performed operations with over 45,000 undertaken in the UK every year

- TURP is the telescopic removal of the obstructing part of a prostate using diathermy.

- Post-TURP bleeding risk is the most notable complication potentially leading to reoperation and blood transfusions

Methodology

- Data collected

-> no. of high-risk patients

-> no. of pharmacological thromboprophylaxis prescribed

-> no. of mechanical thromboprophylaxis prescribed

-> no. of patients with significant bleeding needing blood transfusion/reoperation

- Repeat audit performed subsequently to complete the audit cycle

Standard

According to the European Association of Urology (EAU), the use of pharmacological prophylaxis post-TURP is prohibited while those deemed high risk for venous thromboembolism (VTE) are recommended only mechanical prophylaxis until ambulation.

RESULTS

- A total of 328 patients were included

Aim

Our closed loop audit aimed to assess mechanical and pharmacological thromboprophylaxis prescribing in patients who underwent TURP

Lessons learnt included the importance of repeat audit to measure the effect of change and the continuous process of maintaining patient safety.

- 0.6% (1st cycle) vs 0% (2nd cycle) of patients required a blood transfusion due to significant post-op haemorrhage

Application and Appropriateness of IPC prescription on the stroke rehabilitation unit

By Dr Tan, Dr Lim, Dr El-Sayegh

Introduction

Incidence of deep vein thrombosis is the highest among patients who are immobile. In this project, we are interested in post-stroke patients. Deep vein thrombosis can lead to potentially fatal complications such as pulmonary embolism. The CLOT3 trial has shown that intermittent pneumatic compression (IPC) significantly reduced the risk of all DVTs. We measured if healthcare workers are compliant in prescribing and applying IPC to patients and the consistency of patients receiving this.

Methodology

This audit is based on National Clinical Guidelines for Stroke (2016) 3.13.1 recommendations where patients with immobility after acute stroke should be offered IPC within 3 days of admission and this treatment should be continuous for 30 days or until the patient is mobile or discharged. A crosssectional audit of 20 inpatients admitted to a stroke rehab unit was conducted, with the primary outcome as clarity of documentation of IPC prescription on the drug chart and reasons if omitted. The secondary outcome measured was the consistency of IPC application to patient if prescribed.

Result

Pre-intervention, there were 30% (6 out of 20) of inappropriate IPC prescription. As for secondary outcome, there were less than half of the IPCs were applied correctly, with the majority cause being post-physio and postmobilizing.

Interventions included posters as reminder to both prescribing doctors and nurses. We also held brief teaching sessions to healthcare workers to reinforce the importance of IPCs application.

Post-intervention, the percentage of inappropriate IPC prescription dropped to only 5% and the consistency of application increased to 76%.

Pre-Intervention

Appropriate

Discussion

Post-Intervention

Inappropriate

Appropriate

Inappropriate

Evidence has shown that IPCs application reduces the VTE risk, and are an inexpensive preventive management (30 pounds per pair). Education and aide-memoire for healthcare workers (healthcare assistant, nurses, doctors, pharmacist, and physiotherapist) should be provided, particularly during changeover period, to ensure optimal IPCs prescription and application. A pathway should be developed to mitigate harm should IPCs not be appropriately prescribed or applied.