Improving venous thromboembolism (VTE) prophylaxis for hospitalized malignant hematology/bone marrow transplant (heme/BMT) patients.

Abstract

79 Background: Hospitalized patients on the heme/BMT service at our academic cancer center have historically not received pharmacologic VTE prophylaxis (VTEP) due to concerns regarding thrombocytopenia and bleeding risk. However, a retrospective review of heme/BMT admissions from 2009 to 2013 revealed that 59% of hospital-acquired VTE cases occurred at a platelet count > 50 x 10E9/L, suggesting missed opportunities for VTE prevention. Methods: To implement VTEP on the heme/BMT service, a multidisciplinary quality improvement team developed a pilot intervention with 5 strategies: 1) identification of heme/BMT-specific contraindications to VTEP, 2) standardized use of VTEP for all heme/BMT patients unless contraindications are present, 3) hold parameter for platelet count < 50 x 10E9/L within the VTEP order, 4) note template to document VTEP plan, and 5) provider, nurse, pharmacist, and patient education. We conducted audit and feedback every two weeks for two process measures: VTEP ordered for eligible patients (pre-pilot VTEP ordered for < 1%) and VTEP plan documented (pre-pilot documentation of 23%). Patients on therapeutic anticoagulation were excluded. We also tracked major bleeding events among patients receiving VTEP. Results: Since pilot implementation in July 2015, 105 patients admitted during audit periods met the inclusion criteria; 11 patients on therapeutic anticoagulation were excluded. Contraindications to VTEP were present for 56 patients, most commonly platelet count < 50 x 10E9/L (46%), central nervous system lymphoma (23%), and anticipated procedure (21%). Among the 49 eligible patients, VTEP was appropriately ordered for 42 (86%). VTEP plan was documented for 102 patients (97%). One VTEP-associated bleed occurred in a patient with recent polypectomy, prompting the addition of a new contraindication for recent procedures. Conclusions: Our multidisciplinary pilot successfully improved VTEP orders for eligible heme/BMT patients from < 1% to 86% and VTEP plan documentation from 23% to 97%. Rates of hospital-acquired VTE and major bleeding are being tracked prospectively to evaluate efficacy and safety.