Venous Thromboembolism Prophylaxis on Inpatient Psychiatry Units

To the editor: Among hospitalized patients, venous thromboembolism is a significant cause of morbidity and mortality, especially if complicated by pulmonary embolism (1) . Historically, one in three hospitalized patients at risk for venous thromboembolism has received prophylaxis (2) . In 2001, the American College of Chest Physicians recommended that hospitals develop protocols for prevention of venous thromboembolism (3) . Although many institutions have subsequently developed protocols for prevention, certain hospitalized patients are often excluded from these protocols (4) .

In 2004, our hospital instituted venous thromboembolism prophylaxis in medical and surgical, but not psychiatry, units. Our admission order sets require selection of one of the following prophylaxis options: 1) heparin, 5,000 U subcutaneous t.i.d.; 2) enoxaparin, 40 mg subcutaneous daily; 3) enoxaparin, 30 mg subcutaneous daily for patients with a creatinine clearance <30 ml/min; and 4) enoxaparin, 40 mg subcutaneous b.i.d. for patients weighing >150 kg. Withholding venous thromboembolism prophylaxis is allowed, but a stated reason is required (i.e., not indicated, contraindicated, or patient refusal). Our venous thromboembolism prophylaxis order set includes website links to information on risk factors, prophylaxis indications, and prophylaxis contraindications.

We present a case of uncomplicated venous thromboembolism discovered in an inpatient during his discharge physical examination.

The purpose of the present case was to heighten awareness of venous thromboembolism among inpatient psychiatrists who care for older patients with organic mental diseases or patients with general medical comorbidities. Psychiatric inpatients demonstrating restricted mobility and who have at least one venous thromboembolism risk factor and lack contraindications for prophylaxis should be reviewed for prophylaxis. It is likely that the patient’s venous thromboembolism in the present case would have been prevented had prophylaxis been instituted. Inpatient psychiatry services, especially those managing geriatric patients, might consider incorporating venous thromboembolism prophylaxis orders routinely on admission.