2011 RQHR Venous Thromboembolism Prophylaxis Audit : Data ...



|2011 RQHR Venous Thromboembolism Prophylaxis Audit : Data Collection Form |

|Patient Code (patient initials and MRN): ______________________________________ |

|Audited by: _________________ Date: _____________________ Ward: ______________ |

|Section A: Exclusion Criteria for VTE Prophylaxis Audit (check all that apply) |

|Current therapy: |

|Heparin (except heparin lock/flush) |Rivaroxaban |

|Low molecular weight heparin |Dabigatran |

|(i.e. enoxaparin or dalteparin) |Thromboembolic elastic stockings |

|Warfarin |Intermittent pneumatic compression |

|Patient population: |

|Palliative Care (followed by Palliative Care or CTC [compassionate terminal care]) |

|Admitted for chemotherapy or radiation with passes for evenings and weekends (PH 3B) |

|No acute medical conditions and awaiting placement in long-term care |

|Age less than 18 years of age |

| |

|If you selected any of the above options do not complete the rest of the form. |

|Section B: VTE Risk Stratification – Class A (any one of these risk factors require prophylaxis, check all that apply) |

|Major surgery (especially abdominal, pelvic, orthopedic) |Lower extremity paralysis |

|Trauma |Mechanical ventilation |

|Ischemic stroke |Active cancer and its treatment |

|Spinal cord injury | |

|Section C: VTE Risk Stratification – Class B (any 2 of these risk factors require prophylaxis, check all that apply) |

|Admitted due to congestive heart failure |Inflammatory bowel disease (history or current reason for admission) |

|Admitted due to severe respiratory disease |Pregnancy/post-partum |

|Prolonged immobility (>16h in bed/day x ≥3 days or on isolation) |Nephrotic Syndrome |

|Active cancer |Collagen Vascular Disease |

|Previous VTE |Indwelling central venous catheter or PICC line |

|Sepsis |Congenital and/or acquired thrombophilia diseases |

|Section D: High Bleeding Risk or Contraindications to Pharmacological VTE Prophylaxis (check all that apply) |

|Active bleeding |Uncontrolled hypertension |

|Thrombocytopenia (platelets 200 and/or DBP120) |

|Heparin Induced Thrombocytopenia |Frank intracranial or intraocular hemorrhage (within past 5 days) |

|Lumbar puncture within 24 hours | |

|If you selected any of the above Section D check boxes and the patient requires VTE prophylaxis, proceed to Section H. |

|Section E: Other Factors to Consider re: Bleeding Risks |

|Type of cancer: |Medications which may increase bleeding risk: |

|Hematological cancers (e.g. leukemia) |ASA |

|Lymphoma |Clopidogrel |

|Brain tumours |NSAIDs |

| |Corticosteroids |

|Section F: VTE Risk Category & Recommendations |

|High risk (any 1 risk factor from Class A or 3 risk factors from Class B) |

|Medical Patient |

|Enoxaparin 40mg subq q24h until discharge |

|Enoxaparin 20mg subq q24h until discharge (if Clcr ................
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