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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 issues related to behavioral health:
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
Parker C, Coupland C, Hippisley-Cox J. Antipsychotic drugs and risk of venous thromboembolism: nested case-control study. BMJ 2010; 341:c4245
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
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