Addressing psychiatric inpatients for VTE prevention

A big thanks to Jo Jerrome and Prof Beverley Hunt for inviting me to write here! I’m a psychiatry trainee in Aberdeen. “A psychiatrist on Thrombosis UK…?” I hear you ask? Well yes. Please hear me out a minute. I’ve been a longstanding follower of Thrombosis UK, and this all began when I was having an e-mail exchange with Professor Hunt, and the point of VTE prophylaxis in psychiatry came up.

While there are already some NICE guidelines for psychiatry, which point at the NICE VTE prophylaxis tool, the tool itself is often irrelevant to psychiatry. Patients often have no co-morbid medical illness, and the majority of them are walking around the ward, and off the ward, just like they would at home. Most of my patients do not need VTE prophylaxis.

A select few, however, aren’t so lucky. The severely depressed, who don’t get up save for going perhaps to the toilet, and need constant encouragement to drink (often facing dehydration and AKIs), as well as those who are often heavily sedated or restrained, however, would benefit from it. Although I’m yet to see any of my patients develop a DVT or PE (I do put them on dalteparin empirically when I think they need it), I thought that we could start a discussion here.

Do we need a tool for VTE prophylaxis specifically aimed at psychiatric patients? I think so.

The scenarios in psychiatry that *really* need DVT prophylaxis, that I can think of, are:

  • Severely depressed / depressive bipolar patients who aren't getting up and often not drinking.
  • Patients who are being confined to room or even "nursed on mattress" (which is an euphemism for being restrained for a prolonged time, usually by 2 or 3 nurses and bean bags - these you tend to see in IPCU).
  • Agitated (usually psychotic or bipolar, plus the odd borderline EUPD) patients who are getting sedated often, who then get sleepy and lie in bed for long spells.
  • Psychiatric inpatients with medical comorbidities that warrant it

Rather than adding the 666th or so diabolical proforma to the admission paperwork (our admission paperwork is already some 30 pages long for the doctors, and about as many for the nurses!!), we’re going to try and see if a simpler way of screening could be implemented - something along the lines of:

  • Does this patient have any medical conditions that might require thromboprophylaxis? -> Fill out full screening tool.
  • Is this patient having a depressive episode?
  • Have they been nursed in room or on restrained on mattress since admission?
  • Are they requiring frequent sedation?

If YES to any of these questions, assess mobility. If patient is spending or you foresee them to be spending more than X% of the day in bed or restrained, assess for bleeding risk and give VTE prophylaxis if no contraindications.

I suppose the thing to decide here is how many hours would we see as the cut-off that someone can spend in bed without needing VTE prophylaxis, as there will be a gradient between the extremely depressed who never gets up, and the patients who walk around like they would at home and go out the ward for cigarettes, etc.
Most importantly, however, I think that VTE prophylaxis in psychiatry needs sound clinical judgment rather than algorithmic “guideline-think”.

To illustrate, here’s a couple of scenarios of two patients who on the surface are both “nursed in room” and at times restrained:
The first patient is an 18 year old with an eating disorder who spends all of her time awake exercising, is on a constant observation, and whenever she feels the guard is faltering, she takes that opportunity to harm herself as seriously as she can, from smashing doors onto her hand to breaking a window and severing her carotid artery with a shard (and heavens know how she lived through that one). Needs to be restrained at times when she starts episodes of self-harm. She's covered in bruises.

Definitely NOT a candidate for anticoagulation of any kind.

Another one, nursed in room, psychotic man in his early 60s who at the height of his illness became agitated and aggressive, attempting to strangle staff with no warning at all, requiring IM sedation and some restraint every day, after which he passes out on his bed for several hours. Smokes about 60 a day whenever he's well enough to be allowed out, and probably has some degree of peripheral vascular disease.

Definitely a candidate for anticoagulation,

at least while he's too unwell to go anywhere outside his room. Perhaps not so much so when he's well enough to walk down up and down a flight of stairs for each of his fags.

So simply making a blanket policy might not capture the nuances of psychiatric situations.

I would also propose to have a "are they self-harming" question in the bleeding risk. I'm not going to give any dalteparin to someone who's banging their head on the walls every now and then, or slashing themselves with razorblades, and, well, I'm sure you get the point :)

Like any good guideline, a well thought tool would be something that nudges doctors to use clinical judgment rather than an algorithm that takes the decision out of their hands: most situations in psychiatry are not black and white and require many angles of thought.

Wanna help us make this tool a reality? I’d love for you to get in touch!

Dr Salvatore Cognetti is a Psychiatric doctor based in Scotland

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