A undergone total knee replacement, 7 were excluded because they were receiving anticoagulation before admission, and 1 was excluded because of an order for 6 months of anticoagulation therapy in the community to treat deep vein thrombosis that occurred in the hospital. Of the patients who had undergone total hip replacement, 7 were excluded because they lacked a personal health number (out-of-province patients), 1 was excluded because of active gastrointestinal bleeding, and 1 was excluded because of anticoagulation before admission. Of the patients who had undergone hip fracture surgery, 4 were excluded because of active gastrointestinal bleeding, 2 were excluded because of anticoagulation before admission, and 1 was excluded secondary to thrombocytopenia. This left a cohort of 170 patients: 56 who had undergone total knee replacement, 51 who had undergone total hip replacement, and 63 who had undergone hip fracture surgery. Although this cohort was not large enough to meet the predetermined sample size, it was sufficient to generate 95% confidence that the 170 selected charts were a representative sample of the 510 patients who underwent total hip or knee replacement surgery or hip fracture repair during the study period (with a margin of error of Ā± 6.02%, with the identified guideline adherence rate of approximately 40%; see below).

Only 28 (44%) of the 63 patients who underwent hip fracture surgery, 24 (47%) of the 51 patients who underwent total hip replacement, and 21 (38%) of the 56 patients who underwent total knee replacement received the minimum recommendation of at least 10 days of thromboprophylaxis (Table 1). A separate analysis of in-hospital data revealed that only 25 (40%) of the 63 patients who underwent hip fracture surgery, 6 (12%) of the 51 patients who underwent total hip replacement, and 2 (4%) of the 56 patients who underwent total knee replacement received prophylaxis for at least 10 days during their hospital stay; most patients were discharged before they had received the minimally recommended duration of therapy.
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Table 1. Duration of Thromboprophylaxis

Type of Surgery; No. (%) of Patients

Duration of Therapy

Hip Fracture Surgery
(n
= 63)

Total Hip Replacement (n = 51)

Total Knee Replacement
(n
= 56)

< 10days

35 (56)

27 (53)

35 (63)

10-27days

16 (25)

20 (39)

18 (32)

> 27days

12 (19)

4 (8)

3 (5)

An observational analysis by risk category showed no apparent correlation between extended duration of thrombo- prophylaxis and patients’ associated risk factors for venous thromboembolism (Table 2). Despite their being in the highest-risk group, 62% of the patients at risk level 3 who underwent hip fracture surgery, 50% of the patients at risk level 3 who underwent total hip replacement, and 62% of the patients at risk level 3 who underwent total knee replacement received less than the recommended minimum of 10 days of thromboprophylaxis. In fact, only 23%, 14%, and 8% of the patients with risk level 3 in the groups who underwent hip fracture surgery, total hip replacement, and total knee replaceĀ­ment, respectively, received the recommended extended duration of thromboprophylaxis (greater than 27 days).
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Table 2. Duration of Thromboprophylaxis with Risk Stratification

Duration of Therapy; % of Patients

Risk Level*

< 10

Days

10-27

Days

> 27

Days

Hip fracture surgery


0


100


0


0


1


44


36


21


2


67


0


33


3


62


15


23

Total hip replacement


0


71


29


0


1


53


37


11


2


45


55


0


3


50


36


14

Total knee replacement


0


43


57


0


1


61


32


7


2


88


13


0


3


62


31


8