国内肿瘤医院重症从业人员静脉血栓栓塞症预防管理知识和执行力的多中心现状调查

The current knowledge and execution status of venous thromboembolism prevention and management among critical care practitioners of cancer hospitals in China: a muticenter survery

目的了解当前国内肿瘤医院重症从业人员静脉血栓栓塞症(VTE)预防管理知识和执行力现状。方法采用自行设计问卷并以电子问卷形式对中国抗癌协会(CACA)肿瘤重症分会下注册的医务人员进行调查,409名医务人员参与本次调查,问卷全部有效。将409名参与调查的医务人员按职业分为医生组(142名)和护士组(267名),分析医务人员对VTE预防的基本认知情况、VTE预防的日常实践和肿瘤手术及非手术重症患者的预防性抗凝情况。结果参与调查的医务人员来自全国17个省、4个直辖市的24家肿瘤医院重症医学科,占CACA肿瘤重症分会注册人数的29.0%。①医务人员对VTE预防的基本认知情况:参与调查的医院中已建立VTE质控体系的占45.8%(11/24),医务人员中非常关注VTE的比例为66.5%(272/409),医生组对VTE非常关注的比例、认为VTE对预后有显著影响的比例均明显高于护士组〔分别为83.8%(119/142)比 57.3%(153/267)、84.5%(120/142)比 74.9%(200/267),均 P<0.05〕;医生组认为应积极预防 VTE 的比例高于护士组[70.4%(100/142)比69.3%(185/267)〕,但两组比较差异无统计学意义(P>0.05)。②VTE预防的日常实践情况:熟悉中国临床肿瘤学会(CSCO)VTE指南的医务人员比例较熟悉美国胸科医师学会(ACCP)、美国国立抗癌网络(NCCN)VTE 指南的比例明显增多[61.4%(251/409)比 38.9%(159/409)、38.1%( 156/409)];99.0%(405/409)的医务人员认为需要指南指导肿瘤重症患者的VTE预防管理,但有60.6%(248/409)的医务人员认为现有指南执行需要结合临床实际情况进行调整;85.1%(348/409)的医务人员对科室内患者进行定期VTE风险评估;81.9%(335/409)的医务人员能根据风险评估结果选择不同VTE预防策略;66.7%(273/409)的医务人员选择指南推荐的Caprini评分预测VTE风险。③肿瘤患者的预防性抗凝:对于外科术后肿瘤重症患者,有78.5%(321/409)的医务人员进行预防性抗凝,在患者能下地活动后就停用机械性预防抗凝的比例和停用预防性抗凝药物的比例分别为66.3%(271/409)、54.0%(221/409);对于肿瘤非手术重症患者,仅有9.5%(39/409)的医务人员进行常规预防性抗凝,82.4%(337/409)的医务人员认为需要综合评估患者抗凝获益与出血风险后考虑预防性抗凝,在患者能下地活动后就停用机械性预防抗凝的比例为61.1%(250/409),停用预防性抗凝药物的比例为42.3%(173/409)o结论本次问卷调査结果展现了国内肿瘤重症从业人员VTE预防管理的认知及实践情况,反映出肿瘤重症患者VTE预防存在抗凝不足的现状。现有指南没有针对性指导肿瘤重症患者VTE预防工作,使得医务人员的临床决策更多需要结合自己的临床经验。建立和完善国内肿瘤重症领域血栓防治的专家共识或指导意见,有利于规范VTE的预防管理工作,对提高国内肿瘤重症患者VTE防治的整体水平具有重大意义。

Objective To investigate the current knowledge and execution status of venous thromboembolism (VTE) prevention and management among critical care practitioners in cancer hospitals in China. Methods A self-designed electronic questionnaire was used to survey the registered medical members from the Critical Care Medicine Society of China Anti-Cancer Association (CACA), 409 practitioners participated in the survey with validated questionnaires. The respondents were divided into physician group (n = 142) and nurse group (n = 267) according to the occupation. The practitioners' basic knowledge situation of VTE prevention, the daily practice of VTE prophylaxis, and the prevention of anti-coagulation situation in patients undergoing tumor surgery and non-surgery treatment were analyzed. Results Respondents from 24 Departments of Critical Care Medicine of Cancer Hospitals in 17 provinces and 4 municipalities across China participated in the survey, accounting for 29.0% of the total registered members of the Critical Care Medicine Society of CACA.① Practitioners' current basic knowledge and attitude of VTE prevention: 45.8%(11/24) of the hospitals involved in the survey had established VTE quality control system;66.5%(272/409) of the respondents very concerned about VTE;the proportion of respondents very concerned about VTE [83.8%(119/142) vs. 57.3%(153/267)] and proportion of respondents who thought that VTE had a significant effect on prognosis [84.5%(120/142) vs. 74.9%(200/267)] in physician group were significantly higher than those in nurse group (both P < 0.05);a similar proportion of the respondents in physician and nurse groups suggested energetic prevention of VTE should be carried out [70.4%(100/142) vs. 69.3%(185/267), P > 0.05].② Daily practice of VTE prevention: compared with American College of Chest Physicians (ACCP) and National Comprehensive Cancer Network (NCCN) guidelines, the proportion of the respondents who were familiar with the VTE guidelines from the Chinese society of clinical oncology (CSCO) was significantly higher [61.4%(251/409) vs. 38.9%(159/409), 38.1%(156/409)];99.0%(405/409) of the respondents believed guidelines were necessary for the VTE prevention and management of critically ill cancer patients, meanwhile 60.6%(248/409) suggested the implementation of the current guidelines needed to be adjusted according to the clinical practical situation;85.1%(348/409) of the respondents performed regular VTE risk assessment in clinical practice;81.9%(335/409) implemented VTE prevention strategy based on difference in risk stratification results;66.7%(273/409) of the respondents selected Caprini score recommended by the guidelines for VTE risk assessment.③ VTE prophylaxis for critically ill cancer patients: for postoperative cancer patients, 78.5%(321/409) of the respondents implemented both mechanical prophylaxis and anticoagulants for prevention of VTE, 66.3%(271 /409) respondents discontinued the mechanical prophylaxis and 54.0%(221 /409) discontinued prophylactic anticoagulation once the patients were ambulatory;for patients with critical cancer illness under medical treatment, only 9.5%(39/409) of the respondents routinely implemented prophylactic anticoagulation, while the majority of respondents 82.4%(337/409) implemented prophylactic anticoagulation based on a comprehensive risk assessment for bleeding;61.1%(250/409) discontinued mechanical prophylaxis and 42.3%(173/409) discontinued prophylactic anticoagulation once the patients were ambulatory. Conclusions The results of this nation-wide survey reveal the current knowledge and practice status of the VTE prevention and management among critical care practitioners in China, indicating that VTE prophylactic anti-coagulation practice for critically ill cancer patients is still suboptimal. The present guidelines are not directing to the VTE preventive works for such patients, resulting in that the VTE preventive strategy remains largely based on experiences of medical workers rather than scientific evidence from clinical trials. Establishing and improving expert consensus or guidelines for critical cancer patients are beneficial and of great importance to elevate the level of standardizing prevention and management of VTE in China.