Introducing a specialist drug kardex can significantly change prescribing practices for VTE in cancer patients.

Sir, We read with interest the results of the ENDORSE Study 1 . This study clearly demonstrated a high prevalence of risk for venous thromboembolism (VTE) and a low rate of prophylaxis use, particularly in medical patients. Of those at-risk medical and surgical patients with no contraindication to VTE prophylaxis, overall 57% received recommended VTE prophylaxis, with 64% surgical and 47% medical patients, receiving the recommended prophylaxis, respectively. We note that with regard to risk factors present prior to admission, active malignancy was an issue in only 6.7% (n=19) of the patients included in the study, and as inpatients only 2 patients (0.7%) underwent cancer therapy. As such, cancer patients are perhaps underrepresented in this cohort. Cancer is a well-known risk factor for the development of VTE, and VTE is a common and life-threatening condition in cancer patients, resulting in a shorter life expectancy than either cancer patients without VTE or noncancer patients with VTE 2,3 . Effective thromboprophylaxis reduces the risk for VTE and improves outcomes. However, mirroring general medical and surgical patients, VTE prophylaxis continues to be underprescribed in cancer patients. Recognizing the clinical burden of VTE in cancer patients, the National Comprehensive Cancer Network recently released updated guidelines for VTE prevention and management 4 . These guidelines categorise hospitalised cancer patients as a group at high or highest risk for VTE who should be considered for pharmacological thromboprophylaxis, provided no contraindications exist to anticoagulant therapy. Currently, no guidelines exist in our institution for primary prophylaxis of VTE. As a pilot scheme for the hospital, the oncology department was introduced with a re-designed drug prescription kardex which included a component which prompted the admitting physician to assess VTE risk prior to prescribing medications. Compliance of the oncology department to the current NCCN guidelines for VTE prophylaxis was assessed for the last 23 patients admitted prior to the new kardex and the first 10 patients admitted with the altered kardex. Data was collected retrospectively analysing patient medical records and prescription kardexes to determine changing practices following the introduction of the new kardex. Similar to the ENDORSE study, a low rate of VTE prophylaxis prescription was initially noted. Of the 21 patients who should have been given primary prophylaxis with enoxaparin, 38.1% (n=8) were prescribed it, while 2 patients were continued on therapeutic tinzaparin for previous thromboembolic events. Introduction of the new kardex resulted in significantly improved thromboprophylaxis prescription practice, with 88.9% (n=8) of patients whoshould have been prescribed VTE prophylaxis receiving enoxaparin, while 1 patient continued their therapeutic tinzaparin for previous thromboembolic events. Authors of the ENDORSE study mention a number of successful strategies reported in the literature to improve rates of VTE prophylaxis 1 . Our study reiterates that simple steps, such as introducing a re-designed hospital admission prescription kardex, can significantly improve VTE prescription practices. We agree with the authors that awareness of VTE guidelines should be an integral component of health policy. N Coleman, R Young, M Greally, L O’Riordan, O Breathnach, L Grogan Beaumont Hospital, Beaumont, Dublin 9 Email: [email protected]