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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