Enhancing Patient Care: Venous Thromboembolism Prophylaxis in the Emergency Department.

European Guidelines on perioperative venous thromboembolism prophylaxis: Executive summary.

Review question/objective The objective of this review is to identify, appraise and synthesise the best available evidence on the facilitators and barriers to compliance with Venous Thromboembolism (VTE) risk assessment and prophylaxis clinical practice guidelines in the acute care setting. More specifically, the review question is: To what extent are clinical practice guidelines for risk assessment and prophylaxis of VTE adhered to in the acute care setting, and what are the facilitators and barriers? Inclusion criteria Types of participants This review will consider any studies that include all health care professionals regardless of their designated involvement with venous thromboembolism risk assessment and prophylaxis in the acute care setting. Phenomena of interest This review will consider studies that evaluated the facilitators and barriers to venous thromboembolism compliance with clinical practice guidelines in the acute care setting. The qualitative component of the review will consider as phenomena of interest any studies that identify facilitators and/or barriers to compliance with clinical practice guidelines in relation to venous thromboembolism risk assessment and prophylaxis in the acute care setting. The quantitative component of the review will consider any studies that report on the barriers and facilitators to compliance with clinical practice guidelines in relation to venous thromboembolism risk assessment and prophylaxis in the acute care setting. The textual component of the review will consider any paper that discusses the facilitators and/or barriers to compliance with clinical practice guidelines in relation to venous thromboembolism risk assessment and prophylaxis in the acute care setting. Types of outcomes This review will consider studies that include measures of compliance as their outcome measures. The qualitative component of the review will consider any studies that identify facilitators and/or barriers to compliance with clinical practice guidelines in relation to venous thromboembolism risk assessment and prophylaxis in the acute care setting. The quantitative component of the review will consider any studies that report on the barriers and facilitators to compliance with clinical practice guidelines in relation to venous thromboembolism risk assessment and prophylaxis in the acute care setting. The textual component of the review will consider any paper TRUNCATED AT 350 WORDS

Venous Thromboembolism Risk Assessment and Prophylaxis: A Comprehensive Systematic Review of the Facilitators and Barriers to Healthcare Worker Compliance with Clinical Practice Guidelines in the acute care setting.

Standardized Approach to Peri-Operative and Peri-Procedural Chemical Venous-Thromboembolism Prophylaxis

Case Presentation : A 29-year-old woman presented to the emergency department with complaints of pleuritic chest pain, fever, and left ankle swelling and tenderness. Cardiac examination was normal except for tachycardia. A chest computed tomography scan with contrast demonstrated extensive bilateral pulmonary emboli. Thirteen days previously, an intoxicated driver with multiple prior convictions for driving under the influence of alcohol crashed head-on into her car at a high speed. She was 8 months’ pregnant and suffered the loss of the child. She spent 7 days in the hospital and underwent cesarean section, exploratory laparotomy, and splenectomy. No preoperative pharmacological prophylaxis against venous thromboembolism (VTE) was administered. VTE, which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is an important and common complication of general surgery. A new era in the postoperative management of surgical patients began in 1975 when the effectiveness of low-dose heparin in preventing postoperative DVT and PE was established by the pivotal International Multicenter Trial.1 The dose was 5000 U subcutaneously every 8 hours, with the first injection administered 2 hours before the skin incision. Compared with control, the incidence of DVT in patients receiving heparin decreased from 24.6% to 7.7%. Similarly, the incidence of autopsy-proven PE was reduced 8-fold. The results of this trial introduced and validated the concept of using low-dose heparin to prevent postoperative VTE. This trial revolutionized surgical practice. By 1994, 90% of North American general surgeons reported the routine use of thromboprophylaxis.2 Most postoperative DVT originates in the deep calf veins, primarily within the valve cusps. Most thrombi remain confined to the calf. Propagation into the proximal veins increases the risk of PE. Symptoms and signs of postoperative VTE such as mild hypoxia or low-grade fever are frequently nonspecific. Moreover, clinical manifestations of postoperative VTE may not occur until …

Background: Venous thromboembolism (VTE) is a preventable disease in hospitalized patients; however, VTE prophylaxis is underutilized. Effective strategies for the assessment of individual patients' VTE risk and the provision of VTE prophylaxis are needed. Objective: To evaluate the efficacy of a multidisciplinary intervention designed to improve VTE risk assessment and prophylaxis in at-risk hospitalized patients. Methods: The multidisciplinary intervention to improve VTE risk assessment and prophylaxis consisted of 3 strategies: a broad educational effort, nursing assessment, and pharmacist follow-up. Educational programs were delivered to nursing, pharmacy, and physician staff. Upon admission, all patients were assessed for VTE risk factors by nursing staff. Pharmacists reviewed reports of patients screened to have at least 1 VTE risk factor; for patients not prescribed VTE prophylaxis, pharmacists placed a progress note and VTE prophylaxis order form in the chart. If no prophylaxis was prescribed by the following day, the pharmacist contacted the physician with a verbal recommendation. The impact of this intervention was evaluated by comparing the proportion of patients assessed for VTE risk factors on admission and the proportion of VTE prophylaxis candidates who received prophylaxis, both before and after implementation. Results: A total of 310 patients were included during the 2-month study period. An increase in patients assessed for the presence of VTE risk factors was observed after the intervention (41% vs 87%, p < 0.001). Similarly, an increase in patients prescribed prophylaxis was observed after the intervention (36% vs 63%, p < 0.001). Conclusions: This multidisciplinary approach including education, nursing assessment, and pharmacist follow-up resulted in a significant increase in the rates of VTE risk assessment and prophylaxis.

To Assess the Appropriateness of the Venous Thromboembolism (VTE) Prophylaxis Agent Used Based on the VTE Risk Stratification in Hospitalised Acutely Ill Medical Patients

Commentary In this article, Mendez et al. offer their experience with use of aspirin for venous thromboembolism (VTE) prophylaxis specifically in orthopaedic oncology patients. They conclude that aspirin is a “suitable” chemoprophylactic agent. I wish this were so because aspirin is such a simple agent to prescribe and use. However, few topics in orthopaedics are as controversial as the selection of appropriate prophylaxis postoperatively. Prophylaxis for VTE in general has been the focus of numerous randomized prospective clinical trials with Level-I evidence, but even those have not always agreed. Hence, study panels of the American College of Chest Physicians (ACCP), American Academy of Orthopaedic Surgeons (AAOS), and American Society of Clinical Oncology (ASCO) continue to publish guidelines based on their interpretation of the latest literature. Despite these guidelines, there is considerable flexibility in a physician’s or surgeon’s choices for VTE prophylaxis. The controversy about VTE prophylaxis has been particularly contentious with respect to aspirin. As noted by Mendez et al., the ACCP guidelines recommended against its use in 2008 but then added aspirin as an acceptable agent in 2012. ASCO guidelines recommend against aspirin use and suggest only unfractionated heparin or low-molecular-weight heparin (LMWH) be used for patients with cancer who are undergoing major surgery. However, they do allow for aspirin use in patients on chemotherapy for myeloma. Citing ambiguity in the evidence, the AAOS guidelines allow use of aspirin as well as a pneumatic compressive device or any other chemotherapeutic agent for postoperative VTE prophylaxis following hip and knee arthroplasty. Mendez et al. are correct in asserting that universal surgical guidelines do little to direct the orthopaedic oncologist in the selection of VTE prophylaxis. However, does their article provide us the missing but desired direction? I believe that it is difficult to know how to use their findings. First, the number of patients in their study was relatively small (130 patients with a total of 142 procedures). In a recent systematic review and meta-analysis of computerized clinical decision support systems for VTE prophylaxis, 11 publications (including 9 prospective cohort trials) involving 156,366 subjects (an average 14,408 subjects per trial) were reviewed1. Even among 7 prior studies of VTE in orthopaedic oncology, the average number of patients was 348 (range, 94 to 986). Moreover, 5 of those studies were focused on incidence and risk factors for VTE. The only 2 treatment studies in orthopaedic oncology involved 348 subjects (treated with aspirin and a pneumatic compression device or with LMWH and a pneumatic compression device) and 986 subjects (treated with LMWH)2,3. Second, although this was a retrospective study, and hence intention-to-treat (ITT) analysis was not applicable, the authors clearly intended for all of their patients to receive aspirin; however, only 73% did so. Reasons for protocol deviation included an outpatient operative procedure not requiring chemoprophylaxis, patient refusal, aspirin allergy, VTE history, and a desire for a readily reversible option in case an early return to the operating room was necessary. Third, the orthopaedic oncology patient population studied by Mendez et al. was broad in its scope of inclusion criteria, which included metastatic carcinoma, myeloma, lymphoma, and sarcoma, further diluting the numbers for subgroup analysis. It also differs somewhat from prior reports in that more than one-half of the patients had metastatic carcinoma whereas some larger studies in orthopaedic oncology included predominantly or exclusively patients with sarcoma4,5. Thus, we must greatly temper our enthusiasm for the conclusion that aspirin is a suitable agent with the realization that the data are based on a small number of patients relative to the large body of literature on this topic. Also, the study was not a pure evaluation of patients treated only with aspirin, but rather a real-practice evaluation in which there were protocol deviations for various reasons; hence, its conclusions should not be extended to patients who had outpatient surgical procedures or a VTE history, for instance. Finally, although a broad range of orthopaedic oncology diagnoses were included, this actually makes it difficult to know how readily the results could be applied to patients with any one of those diagnoses. In conclusion, as much as I want aspirin to be a safe and efficacious VTE chemoprophylactic agent for all of my orthopaedic oncology patients, these results should not be interpreted as definitive support until additional studies are done.

149 Background: VTE prophylaxis measures are endorsed by the National Quality Forum in alignment with quality indicators from the Centers for Medicare & Medicaid Services. Accordingly, documentation of VTE risk, prophylaxis measures, and contraindications are recommended for hospitalized patients. To standardize practice we embedded a VTE risk assessment and prophylaxis module into admission and post-surgical order sets (OS), starting August 15, 2011. Methods: A retrospective study of 9,065 cancer patients (≥18 years) admitted to The University of Texas MD Anderson Cancer Center between June 01, 2013 through September 30, 2013. Pharmacological prophylaxis was executed with low-molecular-weight heparin or unfractionated heparin. Mechanical prophylaxis was executed with graduated compression stockings and/or sequential compression devices. Chi-square testing was used to determine the association between categorical variables. All statistically significant levels were determined with P values < 0.05. Results: 7,366 (81%) of all hospital admissions had documented VTE risk assessment and prophylaxis through the standardized VTE module. Before implementation of the new OS, only 40% of eligible patients received an order for VTE prophylaxis. The majority of patients were designated high or moderate risk (91.1%). Patients with high risk were more likely to receive pharmacological prophylaxis than those with moderate risk (74.1% vs. 38.2%, P<0.01). The most frequent contraindications to pharmacological prophylaxis were major surgery with risk of bleeding and thrombocytopenia (Table). Conclusions: Most patients received VTE prophylaxis based on VTE risk levels presented in a standardized OS. There is is limited information in the clinical literature about the impact of VTE prophylaxis on outcomes among cancer patients, we plan to assess anticoagulation-related outcomes in this cohort of patients. [Table: see text]

Objective: To determine the risk profile of venous thromboembolism (VTE) and evaluate VTE prophylaxis implementation of the hospitalized cancer patients in the DissolVE 2 study. Methods: The data of hospitalized cancer patients in the DissolVE 2 study were analyzed. The risk distribution of VTE, preventive measures and in-hospital VTE events of hospitalized patients with tumors were described by percentage and 95% confident interval (CI). Results: A total of 1 535 cancer patients were included. According to the Padua score, 826 (53.8%) patients were at low risk of VTE, while 709 (46.2%) patients were at high VTE risk. VTE events occurred in 4 low-risk patients (0.5%; 95%CI: 0.1%, 1.2%) and 5 high-risk patients (0.7%; 95%CI: 0.2%, 1.6%). The overall incidence was 0.6% (9/1 535, 95%CI: 0.3%, 1.1%). Among patients with high VTE risk, 666 (93.9%) did not receive any VTE prophylaxis, and only 11 (1.6%) patients received appropriate VTE prophylaxis. Among patients who received VTE prevention, no VTE event was observed. Conclusions: Nearly half of the hospitalized cancer patients are at high risk of VTE, but most of them don't receive VTE prophylaxis. The results reflect the insufficient management of VTE risk for hospitalized cancer patients in China, and improvement of awareness and practice of VTE prophylaxis is urgently needed.

Thromb Haemost 2009; 102: 1–2 Venous thromboembolism (VTE) prophylaxis for hospitalised patients at risk for deep venous thrombosis (DVT) or pulmonary embolism (PE) has been underutilised. Consequently, VTE has been identified as the number one cause of preventable death among hospitalised patients. Deaths and non-fatal VTE caused by failure to prophylax occur not only in the hospital but continue for at least several months after hospital discharge. Government policy makers, patients, and health care providers have declared that the contrast between our in-depth knowledge of how to prevent VTE and our lackadaisical implementation of prophylactic measures is unacceptable. In 2008, Steven K. Galson, MD, MPH issued The Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism (1). The Surgeon General estimates that in the United States alone, 100,000 to 180,000 deaths occur annually because of VTE. He states that although “we have made progress in our knowledge of how to prevent, diagnose and treat DVT/PE..., it is also clear that we are not applying that knowledge on a systematic basis.” Meanwhile, Medicare has devised a financial incentive for hospitals to enforce VTE prophylaxis among high-risk patients. Medicare is now authorised to withhold payment to hospitals for treatment of serious preventable complications termed „never events.“ Examples of “never events” include leaving a surgical instrument in the abdomen or transfusing blood with incompatible blood types. Medicare will not pay the incremental cost to manage a “never event,” such as repeat surgery to remove the forgotten surgical instrument or additional hospital care to treat a transfusion reaction resulting from major blood type incompatibility. Rather, the hospital where the error occurred will bear the additional financial burden (2). As of October 1, 2008, Medicare declared the occurrence of VTE after total knee or hip replacement to be a “never event.” This means that hospitals will have to pay for the extra costs of treating postoperative DVT or PE following knee or hip replacement. Quality improvement programs have tried to increase in-hospital VTE prophylaxis rates, because this metric is readily obtainable and easy to understand. Focus is placed on the percent of high-risk hospitalised patients who are receiving VTE prophylaxis. However, this simple statistic does not tell the whole story. The methodology for assessing quality of VTE prophylaxis is far more complex. Patients receiving pharmacological prophylaxis require the right drug, the correct dose, and the optimal dosing regimen with respect to duration of anticoagulant. Those patients with active bleeding or at very high risk of bleeding should receive prophylaxis, but with mechanical measures such as graduated compression stockings or intermittent pneumatic compression devices rather than with anticoagulants. The duration of VTE prophylaxis should extend beyond hospitalisation if the risk factors for PE or DVT have not diminished by the time of hospital discharge. Evidence is compelling that VTE can strike after hospitalization (3). In a survey of 1,897 patients with VTE in the Worcester, Massachusetts area, 74% developed DVT or PE in the outpatient setting; 23% had undergone surgery and 37% had been hospitalised within the prior three months. Of the 516 who had been hospitalised and subsequently developed VTE, 67% developed VTE within one month of the preceding hospitalisation encounter. In a separate prospective RIETE registry of patients with acute VTE, 1,602 postoperative patients were identified (4). The average time elapsed from surgery to acute VTE was three weeks. These findings indicate the need to consider extended VTE prophylaxis after hospital discharge. A collaboration among 14 Swiss hospitals has addressed the issue of quality of VTE prophylaxis. The effort was led by Christoph Kalka of Berne and is reported in the current issue of Thrombosis and Haemostasis (5). They focused on high-risk major orthopaedic or cancer surgery patients and achieved a remarkable rate of 96% in-hospital prophylaxis. I am not aware of any other study that can match these outstanding results for prophylaxis of high-risk hospitalised patients. Under current quality assessment guidelines, this accomplishment will receive universal praise. However, these investigators took the extra, important step of asking whether VTE prophylaxis was appropriately extended after hospital discharge. Orthopaedic surgery patients did © 2009 Schattauer GmbH, Stuttgart

Defining the Risk: Benefit Ratio of Venous Thromboembolism (VTE) Prophylaxis in Hospitalized Cancer Patients

Venous thromboembolism in cancer patients: ESMO Clinical Practice Guideline

Impact of a Program to Improve Venous Thromboembolism Prophylaxis on Incidence of Thromboembolism and Bleeding Rates in Hospitalized Patients During Implementation of Programs to Improve Venous Thromboembolism Prophylaxis

Impact of Surgery Type and Co-Morbidities on Venous Thromboembolism prophylaxis Practices in Patients Undergoing Major Surgical Procedures in Acute Care Hospitals Worldwide: A Subanalysis of Data from the ENDORSE Survey