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Whats New in the
Patient Safety World
February 2020
DVT and Behavioral
Health
In our February 6, 2018 Patient Safety Tip of the Week Adverse Events in Inpatient Psychiatry we
noted that, although deep venous thrombosis (DVT) is relatively rare on
behavioral health units, every year state incident reporting systems receive
reports of DVT or even fatal pulmonary embolism in patients on behavioral
health units. This most often occurs in patients with severe behavioral health
problems that leave them bedridden. Weve seen DVT in one patient who had laid
in bed at home several weeks prior to admission. Therefore, it is essential
that every patient admitted to behavioral health units received an assessment
for DVT risk factors just as if they had been admitted to a med/surg unit.
But, just as your risk of falling may change during a hospital stay, your risk for DVT may also change due to events that happen during a hospital stay. One of those events on a behavioral health unit is the use of restraints. A recent study (Funayama 2020) found that use of physical restraints was associated with a 6-fold higher risk of DVT. The researchers analyzed medical records of over 1300 psychiatric inpatients and compared a physical restraint group (those who had been subjected to physical restraint while hospitalized) to a non-physical restraint group. The physical restraint group had a higher risk for deep vein thrombosis (OR = 6.0). Even after controlling for potentially confounding factors, physical restraints substantially raised the risk of deep vein thrombosis. The physical restraint group had a higher risk for aspiration pneumonia (OR = 4.1) when compared with the non-physical restraint group.
Immobility, of course,
is probably the most important risk factor for DVT and venous thromboembolism.
And, patients on behavioral health units are not immune from the comorbidities
that may predispose to DVT in the general population.
But there are other
risk factors for DVT that occur in the behavioral health population. A
recent study from Taiwan (Lin
2019) found that patients with depressive, bipolar, and schizophrenic
disorders had a roughly 3-fold higher risk of DVT and 2.5-fold higher risk of
pulmonary embolism than the general population. One possible contributing
factor may be the use of certain medications. In our October 2010 What's New in the Patient Safety World column
Antipsychotic
Drugs and Venous Thrombembolism we noted a large population-based case-control study (Parker 2010) showed a 32% increased risk for VTE in
patients prescribed antipsychotic medications within the past 24 months. The
risk was almost double in patients newly prescribed antipsychotics (within the
past 3 months) and was higher for atypical antipsychotics and for low rather
than high potency drugs. The overall absolute risk, however, was low. The
estimated number of excess cases per 10,000 patients was 4 for all ages and 10
for patients aged 65 or older.
Therefore, it is essential that every patient admitted to behavioral
health units receive an assessment for DVT risk factors just as if they had
been admitted to a med/surg unit. And that risk assessment should be updated
when certain events occur during a hospitalization. Perhaps your restraint
protocol should include an item reminding you to update that DVT risk
assessment. Were not advocating that you put such patients on pharmacoprophylaxis. Administration of injections of
prophylactic agents might even be detrimental to a patient with a mental state
that merits restraint use. But that DVT risk assessment should remind you to be
on the lookout for signs or symptoms of DVT or pulmonary embolism. It also
emphasizes the need for frequent release of restraints, and perhaps active or
passive range-of-motion exercises of the limbs. And, of course, any decision
about possible use of DVT prophylaxis should also take into
account any other medical conditions that might increase the risk of
DVT.
Some of our past columns on DVT
risk in behavioral health settings:
- October 2010 Antipsychotic Drugs and Venous Thrombembolism
- May 10, 2016 Medical Problems in Behavioral Heatlth
- February 6, 2018 Adverse Events in Inpatient Psychiatry
Some of our past
columns on issues related to behavioral health:
- January 6, 2009 Preventing Inpatient Suicides
- September 22, 2009 Psychotropic Drugs and Falls in the SNF
- February 9, 2010 More on Preventing Inpatient Suicides
- March 16, 2010 A
Patient Safety Scavenger Hunt
- October 2010 Antipsychotic Drugs and Venous Thrombembolism
- December 2010 Joint Commission Sentinel Event Alert on Suicide Risk Outside Psych Units
- September 27, 2011 The Canadian Suicide Risk Assessment Guide
- December 2011 Columbia Suicide Severity Rating Scale
- July 2012 VA
Checklist Reduces Suicide Risk
- August 2013 Suicide
Attempts on Med/Surg Units
- January 15, 2013 Falls
on Inpatient Psychiatry
- April 2, 2013 Absconding
from Behavioral Health Services
- August 25, 2015 Checklist
for Intrahospital Transport
- October 6, 2015 Suicide
and Other Violent Inpatient Deaths
- March 2016 TJC Sentinel Event Alert on Preventing
Suicide
- April 12, 2016 Falls from Hospital Windows
- May 10, 2016 Medical Problems in Behavioral Heatlth
- February 14, 2017 Yet More Jumps from Hospital Windows
- March 14, 2017 More on Falls on Inpatient Psychiatry
- August 29, 2017 Suicide in the Bathroom
- December 12, 2017 Joint Commission on Suicide Prevention
- February 6, 2018 Adverse Events in Inpatient Psychiatry
- July 10, 2018 Another Jump from a Hospital Window
- September 18, 2018 More on Hospital Suicides
- January 22, 2019 Wandering Patients
- January 29, 2019 National Patient Safety Goal for Suicide
Prevention
- July 30, 2019 Lessons from Hospital Suicide Attempts
- September 3, 2019 Lessons from an Inpatient Suicide
References:
Funayama M, Takata T. Psychiatric inpatients subjected to physical restraint have a higher risk of deep vein thrombosis and aspiration pneumonia. General Hospital Psychiatry 2020; 62: 1-5
https://www.sciencedirect.com/science/article/pii/S0163834319303378
Parker C, Coupland C, Hippisley-Cox J. Antipsychotic drugs and risk of venous thromboembolism: nested case-control study. BMJ 2010; 341:c4245
https://www.bmj.com/content/bmj/341/bmj.c4245.full.pdf
Lin C-E, Chung C-H, Chengh L-F, Chen W-C. Increased risk for venous thromboembolism among patients with concurrent depressive, bipolar, and schizophrenic disorders. General Hospital Psychiatry 2019; 61: 34-40
https://www.sciencedirect.com/science/article/abs/pii/S0163834319303627
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