Hospital-acquired Venous Thromboembolism Research Articles

Hospital-acquired venous thromboembolism among critically ill children with diabetic ketoacidosis: a multicenter, retrospective cohort study

ObjectivesChildren hospitalized for diabetic ketoacidosis (DKA) may be at increased risk of hospital-acquired venous thromboembolism (HA-VTE). We sought to estimate the incidence of HA-VTE and identify unique prothrombotic risk factors in this population. MethodsWe performed a multicenter, retrospective cohort study using the Pediatric Health Information Systems registry including patients aged 0 to 21 years hospitalized for DKA from January 2017 to December 2023 within 48 participating centers. The primary outcome was the frequency of HA-VTE. Secondary outcomes were rates of cerebral edema, central venous catheterization (CVC), invasive mechanical ventilation (IMV), infection, and length of stay (LOS). An adjusted logistic regression was employed to identify potential HA-VTE risk factors. ResultsOf the 27,613 patients studied, 93 (0.3%) developed a HA-VTE. Compared with those without HA-VTE, those with HA-VTE had a greater median LOS (10 [IQR, 5-21] vs 2 [IQR, 2-3] days) and rates of cerebral edema (25.8% vs 6.6%), CVC (23.7% vs 1.1%), infection (72% vs 23.5%), and IMV (39.8% vs 1.4%; all P < .001). In an adjusted logistic model, factors independently associated with increased HA-VTE were CVC (adjusted odds ratio [aOR], 3.04; 95% CI, 1.49-6.19), infection (aOR, 4.61; 95% CI, 2.81-7.56), IMV (aOR, 9.24; 95% CI, 4.83-17.56), and increasing LOS (aOR, 1.05; 95% CI, 1.02-1.06; all P < .01). ConclusionThe frequency of HA-VTE among critically ill children and young adults hospitalized for DKA was 0.3%. After prospective validation, putative risk factors (ie, CVC, IMV, infection, and extended LOS) may be incorporated into the design of forthcoming pediatric thromboprophylaxis trials.

Factors associated with venous thromboembolism pharmacoprophylaxis initiation in hospitalized medical patients: the Medical Inpatients Thrombosis and Hemostasis study

BackgroundAlthough guidelines recommend risk assessment for hospital-acquired venous thromboembolism (HA-VTE) to inform prophylaxis decisions, studies demonstrate inappropriate utilization of pharmacoprophylaxis in hospitalized medical patients. Predictors of pharmacoprophylaxis initiation in medical inpatients remain largely unknown. ObjectivesTo determine factors associated with HA-VTE pharmacoprophylaxis initiation in adults hospitalized on medical services. MethodsWe performed a cohort study using electronic health record data from adult patients hospitalized on medical services at 4 academic medical centers between 2016 and 2019. Main measures were candidate predictors of HA-VTE pharmacoprophylaxis initiation, including known HA-VTE risk factors, predicted HA-VTE risk, and bleeding diagnoses present on admission. ResultsAmong 111 550 admissions not on intermediate or full-dose anticoagulation, 48 520 (43.5%) received HA-VTE pharmacoprophylaxis on the day of or the day after admission. After adjustment for age, sex, race/ethnicity, and study site, the strongest clinical predictors of HA-VTE pharmacoprophylaxis initiation were malnutrition and chronic obstructive pulmonary disease. Thrombocytopenia and history of gastrointestinal bleeding were associated with decreased odds of HA-VTE pharmacoprophylaxis initiation. Patients in the highest 2 tertiles of predicted HA-VTE risk were less likely to receive HA-VTE pharmacoprophylaxis than patients in the lowest (first) tertile (OR, 0.84; 95% CI, 0.81-0.86 for the second tertile; OR, 0.95; 95% CI, 0.92-0.98 for the third tertile). ConclusionAmong patients not already receiving anticoagulants, HA-VTE pharmacoprophylaxis initiation during the first 2 hospital days was lower in patients with a higher predicted HA-VTE risk and those with risk factors for bleeding. Reasons for not initiating pharmacoprophylaxis in those with a higher predicted HA-VTE risk could not be assessed.

Mechanical Thromboprophylaxis and Hospital-Acquired Venous Thromboembolism Among Critically Ill Adolescents: A U.S. Pediatric Health Information Systems Registry Study, 2016-2023.

To estimate the rate of mechanical thromboprophylaxis (mTP) prescription among critically ill adolescents using a multicenter administrative database and determine whether mTP prescription is inversely associated with hospital-acquired venous thromboembolism. Multicenter, observational, retrospective study of the Pediatric Health Information Systems (PHIS) Registry cohort, January 2016 to December 2023. Thirty PICUs located within quaternary pediatric referral centers in the United States. Critically ill children 12-17 years old, excluding encounters with a principal diagnosis at admission of venous thromboembolism. mTP prescription within the first 24 hours of hospitalization. A total of 107,804 children met the study criteria, of which 21,124 (19.6%) were prescribed mTP. Hospital center prescribing rates ranged from 1.4% to 65.4% and decreased by 1.6% per year from 28.2% in 2016 to 17.1% in 2023. As compared with those without mTP, those with mTP more frequently had a concurrent central venous catheter (17.2% vs. 9.4%, p < 0.001), underwent invasive mechanical ventilation (37.4% vs. 24.8%, p < 0.001), were admitted for a primary surgical indication (30.9% vs. 12.7%, p < 0.001), and experienced a longer median duration of hospitalization (7 [interquartile range (IQR): 4-15] vs. 4 [IQR: 2-9] d, p < 0.001). Hospital-acquired venous thromboembolism occurred in 2.7% of the study sample and was more common among those with, as compared with without, prescription of mTP (4% vs. 2.4%, p < 0.001). In multivariable logistic regression models for hospital-acquired venous thromboembolism adjusting for salient prothrombotic risk factors, we failed to identify an association between mTP and greater odds of hospital-acquired venous thromboembolism (HA-VTE) among low-, moderate-, and high-risk tiers. However, we cannot exclude the possibility of 17-50% greater odds of HA-VTE in this population. In the multicenter PHIS cohort, 2016-2023, the prescribing patterns for mTP among critically ill adolescents showed a low rate of mTP prescription (19.6%) that varied widely across institutions, decreased annually over the study period by 1.6%/year, and was not independently associated with HA-VTE risk reduction.

Proportion and risk factors for hospital-acquired venous thromboembolism in children: a systematic review and meta-analysis of data from 20 million individuals in 22 countries

BackgroundHospital-acquired venous thromboembolism (HA-VTE) in children has been widely regarded. ObjectivesWe aimed to analyze the proportion and risk factors for HA-VTE in hospitalized children. MethodsWe conducted a comprehensive systematic search across 4 databases from 1990 to 2023. Cochran Q test was used to evaluate the heterogeneity of the effect sizes of study, and I2 statistic was used to quantify the heterogeneity. Pooled estimates were calculated by the inverse-variance weighted method in a fixed-effect model or a random-effect model when heterogeneity was low (I2 < 25%) or high (I2 > 25%), respectively. ResultsIn total, 105 original papers and 20,718,294 patients were included in the study, and the proportion of HA-VTE in children was 4.1% (95% CI, 2.9%-5.2%). Although the proportion of venous thromboembolism increased over the various research periods, the differences were not statistically significant. In the subgroup analysis based on country, the proportion of pediatric HA-VTE was lowest in the United Kingdom and highest in Spain, whereas when based on region, the proportion was lowest in Asia and highest in North America. Multiple HA-VTE risk factors were identified, including central venous catheter use, age of >10 years, surgery, injury, infection, obesity, mechanical ventilation, blood transfusion, malignancy, coagulation and hemorrhagic disorders, and length of hospital stay. ConclusionIn this study, we systematically analyzed the proportion and risk factors of HA-VTE in hospitalized children. Our findings provide valuable insights for the prevention and treatment of HA-VTE in pediatric patients.

Invasive Mechanical Ventilation and Risk of Hospital-Acquired Venous Thromboembolism.

This study sought to estimate the overall cumulative incidence and odds of Hospital-acquired venous thromboembolism (VTE) among critically ill children with and without exposure to invasive ventilation. In doing so, we also aimed to describe the temporal relationship between invasive ventilation and hospital-acquired VTE development. We performed a retrospective cohort study using Virtual Pediatric Systems (VPS) data from 142 North American pediatric ICUs among children < 18 y of age from January 1, 2016-December 31, 2022. After exclusion criteria were applied, cohorts were identified by presence of invasive ventilation exposure. The primary outcome was cumulative incidence of hospital-acquired VTE, defined as limb/neck deep venous thrombosis or pulmonary embolism. Multivariate logistic regression was used to determine whether invasive ventilation was an independent risk factor for hospital-acquired VTE development. Of 691,118 children studied, 86,922 (12.4%) underwent invasive ventilation. The cumulative incidence of hospital-acquired VTE for those who received invasive ventilation was 1.9% and 0.12% for those who did not (P < .001). The median time to hospital-acquired VTE after endotracheal intubation was 6 (interquartile range 3-14) d. In multivariate models, invasive ventilation exposure and duration were each independently associated with development of hospital-acquired VTE (adjusted odds ratio 1.64 [95% CI 1.42-1.86], P < .001; and adjusted odds ratio 1.03 [95% CI 1.02-1.03], P < .001, respectively). In this multi-center retrospective review from the VPS registry, invasive ventilation exposure and duration were independent risk factors for hospital-acquired VTE among critically ill children. Children undergoing invasive ventilation represent an important target population for risk-stratified thromboprophylaxis trials.

A Three-year Retrospective Study Looking at Preventing Hospital Acquired Thrombosis.

Hospital-acquired venous thromboembolism (HA-VTE) is defined as cases of venous thromboembolism (VTE) that occur in a hospital and within ninety days of a hospital admission. Deep vein thromboses (DVTs) most commonly occur within the deep veins of the pelvis and legs. If the thrombus dislodges and travels to the lungs, it can result in a pulmonary embolus (PE). VTE is associated with significant morbidity and mortality, accounting for almost 10% of all hospital deaths. If risk factors are correctly identified and VTE prophylaxis is prescribed, VTE can be a preventable condition. In 2010, NHS England launched The National Venous Thromboembolism Prevention Programme. This included NICE guidance, and a VTE risk assessment tool, which must be completed for at least 95% of patients on admission. The National Thrombosis Survey, published by Thrombosis UK, studied how this program was implemented locally, and audited HA-VTE prevention strategies nationally. Using the Thrombosis Survey and NICE guidance as an aide, this study collects data about hospital-acquired DVT (HA-DVT) at the Queen Elizabeth Hospital in Gateshead (QEH) and aims to: 1. Identify cases of HA-DVT and understand the clinical circumstances surrounding these cases 2. Assess the quality of VTE preventative measures at QEH 3. Outline potential improvement in reducing the incidence of HA-VTE at this hospital Methods: This retrospective cohort study used electronic records to identify all cases of DVT between April 2019 and April 2022 at QEH. Cases of HA-DVT were defined as: a positive ultrasound doppler report and either the case occurring in the 90 days following an inpatient stay, or beyond two days into an admission. For these cases of HA-DVT, we recorded the: reason for admission; admitting specialty; presence of an underlying active cancer and deaths occurring within 90 days of diagnosis. We assessed the quality of VTE preventative measures, by recording the: completion of VTE risk assessments; prescription of weight-adjusted pharmacological VTE prophylaxis and provision of VTE prophylaxis on discharge. For HA-DVT cases occurring within 90 days of an inpatient stay, the preventative measures were assessed on the original admission. Electronic records were used to record the completion rate of the National VTE risk assessment tool for all inpatients during this time frame. The VTE risk assessment tool was completed for 98.5% of all admissions. One hundred and thirty-five cases of HA-DVT were identified between April 2019 and April 2022. Sixteen patients with HA-DVT did not have VTE prophylaxis prescribed on admission. Eleven of these patients had a clearly documented reason why anticoagulation was avoided. In HA-DVT cases where pharmacological VTE prophylaxis was prescribed, 23% were prescribed an inappropriate dose for their weight. If anticoagulation was required on discharge, this was prescribed appropriately in 94% of cases. About 31% of the patients with HA-DVT had an underlying active malignancy. Thirty-nine patients died within 90 days of the DVT being diagnosed; in only 1 case was VTE thought to be a contributing factor to death. The hospital exceeded the national standard of VTE risk assessment completion on admission (greater than 95%). For almost a quarter of patients with HA-DVT, the dose of thromboprophylaxis prescribed was not appropriate for weight. In five cases of HA-DVT, thromboprophylaxis was omitted with no clear justification. HA-DVT often affects the most clinically vulnerable patients and is associated with a high mortality.

Incidence and Characteristics of Hospital-acquired Venous Thromboembolism: A Single-Center Retrospective Study

Incidence and Characteristics of Hospital-acquired Venous Thromboembolism: A Single-Center Retrospective Study

Risk Assessment Models for Venous Thromboembolism in Medical Inpatients

Thromboprophylaxis is recommended for medical inpatients at risk of venous thromboembolism (VTE). Risk assessment models (RAMs) have been developed to stratify VTE risk, but a prospective head-to-head comparison of validated RAMs is lacking. To prospectively validate an easy-to-use RAM, the simplified Geneva score, and compare its prognostic performance with previously validated RAMs. This prospective cohort study was conducted from June 18, 2020, to January 4, 2022, with a 90-day follow-up. A total of 4205 consecutive adults admitted to the general internal medicine departments of 3 Swiss university hospitals for hospitalization for more than 24 hours due to acute illness were screened for eligibility; 1352 without therapeutic anticoagulation were included. At admission, items of 4 RAMs (ie, the simplified and original Geneva score, the Padua score, and the IMPROVE [International Medical Prevention Registry on Venous Thromboembolism] score) were collected. Patients were stratified into high and low VTE risk groups according to each RAM. Symptomatic VTE within 90 days. Of 1352 medical inpatients (median age, 67 years [IQR, 54-77 years]; 762 men [55.4%]), 28 (2.1%) experienced VTE. Based on the simplified Geneva score, 854 patients (63.2%) were classified as high risk, with a 90-day VTE risk of 2.6% (n = 22; 95% CI, 1.7%-3.9%), and 498 patients (36.8%) were classified as low risk, with a 90-day VTE risk of 1.2% (n = 6; 95% CI, 0.6%-2.6%). Sensitivity of the simplified Geneva score was 78.6% (95% CI, 60.5%-89.8%) and specificity was 37.2% (95% CI, 34.6%-39.8%); the positive likelihood ratio of the simplified Geneva score was 1.25 (95% CI, 1.03-1.52) and the negative likelihood ratio was 0.58 (95% CI, 0.28-1.18). In head-to-head comparisons, sensitivity was highest for the original Geneva score (82.1%; 95% CI, 64.4%-92.1%), while specificity was highest for the IMPROVE score (70.4%; 95% CI, 67.9%-72.8%). After adjusting the VTE risk for thromboprophylaxis use and site, there was no significant difference between the high-risk and low-risk groups based on the simplified Geneva score (subhazard ratio, 2.04 [95% CI, 0.83-5.05]; P = .12) and other RAMs. Discriminative performance was poor for all RAMs, with an area under the receiver operating characteristic curve ranging from 53.8% (95% CI, 51.1%-56.5%) for the original Geneva score to 58.1% (95% CI, 55.4%-60.7%) for the simplified Geneva score. This head-to-head comparison of validated RAMs found suboptimal accuracy and prognostic performance of the simplified Geneva score and other RAMs to predict hospital-acquired VTE in medical inpatients. Clinical usefulness of existing RAMs is questionable, highlighting the need for more accurate VTE prediction strategies.

Thrombophilia testing for whom, why and when – a review of current practices

Thromboembolic conditions have accounted for 1 in 4 deaths worldwide in 2010. Thrombosis, which is the common pathogenesis of myocardial infarction, ischaemic stroke, and venous thromboembolism (VTE), is the leading cause of death (1/5 deaths in 1990). Hospital-acquired VTE accounts for approximately 60 percent of all VTEs annually. Others include cancer-associated thrombosis and gender associated risks. In addition to the disease burden, it also causes a significant economic burden world-wide. Multiple diagnostic tests and treatment, prolonged hospital stay and follow-up care, including management of recurrent VTE can be extremely costly. Therefore, it is important to focus on VTE prevention so that health care systems can save money, improve outcomes and save lives. In this background, it is important to have a clear direction as to when, how and whom to test for thrombophilia. Testing for thrombophilias is often performed without a clear understanding of the clinical implications of such results. Guidelines vary in the appropriate use of thrombophilia testing. In this review, these variations in thrombophilia testing and the implications mentioned in the recent guidelines and other articles are discussed. The review of such guidelines, guidance statements, review articles conclude that screening for hereditary thrombophilia has very limited advantage in the management of patients with thrombosis. Screening for antiphospholipid syndrome (APLS) is more important given its high rate of recurrence in both venous and arterial thrombosis. Screening for underlying haematological conditions such as myeloproliferative neoplasms (MPN) and paroxysmal nocturnal haemoglobinuria (PNH) is also considered important.

Hospital-associated venous thromboembolism prophylaxis use by risk assessment at a large integrated health care network in Northern California.

Hospital-acquired venous thromboembolism (HA VTE) is a preventable complication in hospitalized patients. We aimed to examine the use of pharmacologic prophylaxis (pPPX) and compare two risk assessment methods for HA VTE: a retrospective electronic Padua Score (ePaduaKP) and admitting clinician's choice of risk within the admission orderset (low, moderate, or high). We retrospectively analyzed prophylaxis orders for adult medical admissions (2013-2019) at Kaiser Permanente Northern California, excluding surgical and ICU patients. ePaduaKP was calculated for all admissions. For a subset of these admissions, clinician-assigned HA VTE risk was extracted. Descriptive pPPX utilization rates between ePaduaKP and clinician-assigned risk as well as concordance between ePaduaKP and clinician-assigned risk. Among 849,059 encounters, 82.2% were classified as low risk by ePaduaKP, with 42.3% receiving pPPX. In the subset with clinician-assigned risk (608,512 encounters), low and high ePaduaKP encounters were classified as moderate risk in 87.5% and 92.0% of encounters, respectively. Overall, 56.7% of encounters with moderate clinician-assigned risk received pPPX, compared to 7.2% of encounters with low clinician-assigned risk. pPPX use occurred in a large portion of low ePaduaKP risk encounters. Clinicians frequently assigned moderate risk to encounters at admission irrespective of their ePaduaKP risk when retrospectively examined. We hypothesize that the current orderset design may have negatively influenced clinician-assigned risk choice as well as pPPX utilization. Future work should explore optimizing pPPX for high-risk patients only.

Inaccuracy of Initial Clinical Mobility Assessment in Venous Thromboembolism Risk Stratification

BackgroundVenous thromboembolism risk increases in hospitals due to reduced patient mobility. However, initial mobility evaluations for thromboembolism risk are often subjective and lack standardization, potentially leading to inaccurate risk assessments and insufficient prevention. MethodsA retrospective study at a quaternary academic hospital analyzed patients using the Padua risk tool, which includes a mobility question, and the Johns Hopkins-Highest Level of Mobility (JH-HLM) scores to objectively measure mobility. Reduced mobility was defined as JH-HLM scores ≤3 over ≥3 consecutive days. The study evaluated the association between reduced mobility and hospital-acquired venous thromboembolism using multivariable logistic regression, comparing admitting health care professional assessments with JH-HLM scores. Symptomatic, hospital-acquired thromboembolisms were diagnosed radiographically by treating providers. ResultsOf 1715 patients, 33 (1.9%) developed venous thromboembolism. Reduced mobility, as determined by the JH-HLM scores, showed a significant association with thromboembolic events (adjusted OR: 2.53, 95%CI:1.23-5.22, P = .012). In contrast, the initial Padua assessment of expected reduced mobility at admission did not. The JH-HLM identified 19.1% of patients as having reduced mobility versus 6.5% by admitting health care professionals, suggesting 37 high-risk patients were misclassified as low risk and were not prescribed thrombosis prophylaxis; 4 patients developed thromboembolic events. JH-HLM detected reduced mobility in 36% of thromboembolic cases, compared to 9% by admitting health care professionals. ConclusionInitial mobility evaluations by admitting health care professionals during venous thromboembolism risk assessment may not reflect patient mobility over their hospital stay. This highlights the need for objective measures like JH-HLM in risk assessments to improve accuracy and potentially reduce thromboembolism incidents.

Real-world comparative effectiveness of dalteparin and enoxaparin for venous thromboembolism prophylaxis.

Venous thromboembolism (VTE) is a preventable cause of significant morbidity and mortality in hospitalized patients world-wide. In Australia, the low-molecular weight heparins (LMWHs) enoxaparin or dalteparin are usually used as first-line prophylaxis for VTE, though there is uncertainty whether dalteparin has the same effectiveness as enoxaparin in real-world settings. This is relevant because dalteparin is less renally cleared and may be more cost effective than enoxaparin. The aim of this study was to explore VTE event incidence in a general cohort of hospitalized adult inpatients who were prescribed enoxaparin or dalteparin for VTE prophylaxis. A retrospective observational study was conducted at a quaternary hospital in Brisbane, Australia, of patients who had experienced a hospital-acquired VTE from 1 September 2021 to 1 March 2023. Patients were identified from routinely collected data following an in-hospital VTE event, and further data was retrieved retrospectively from the integrated electronic Medical Record (ieMR). Incidence and type of VTE events, LMWH-prescribing patterns, and risk factors were assessed. The incidence of VTE events were similar across the dalteparin and enoxaparin cohorts (42.1 events/10 000 patients vs. 34.4 events/10 000 patients, respectively), although patients prescribed enoxaparin had a higher number of risk factors, particularly obesity and active cancer. Our research indicates comparable incidence of VTE in patients prescribed dalteparin compared with enoxaparin in an Australian hospital general cohort of adult inpatients. Dalteparin may be as effective as enoxaparin for VTE prophylaxis in a real-world cohort of patients, and as such dalteparin may be considered a suitable alternative to enoxaparin for VTE prophylaxis. Further research including large randomized controlled trials are required to confirm these results.

Nomogram for hospital-acquired venous thromboembolism among patients with cardiovascular diseases

BackgroundIdentifying venous thromboembolism (VTE) is challenging for patients with cardiovascular diseases due to similar clinical presentation. Most hospital-acquired VTE events are preventable, whereas the implementation of VTE prophylaxis in clinical practice is far from sufficient. There is a lack of hospital-acquired VTE prediction models tailored specifically designed for patients with cardiovascular diseases. We aimed to develop a nomogram predicting hospital-acquired VTE specifically for patients with cardiovascular diseases.Material and methodsConsecutive patients with cardiovascular diseases admitted to internal medicine of Fuwai hospital between September 2020 and August 2021 were included. Univariable and multivariable logistic regression were applied to identify risk factors of hospital-acquired VTE. A nomogram was constructed according to multivariable logistic regression, and internally validated by bootstrapping.ResultsA total of 27,235 patients were included. During a median hospitalization of four days, 154 (0.57%) patients developed hospital-acquired VTE. Multivariable logistic regression identified that female sex, age, infection, pulmonary hypertension, obstructive sleep apnea, acute coronary syndrome, cardiomyopathy, heart failure, immobility, central venous catheter, intra-aortic balloon pump and anticoagulation were independently associated with hospital-acquired VTE. The nomogram was constructed with high accuracy in both the training set and validation (concordance index 0.865 in the training set, and 0.864 in validation), which was further confirmed in calibration. Compared to Padua model, the Fuwai model demonstrated significantly better discrimination ability (area under curve 0.865 vs. 0.786, net reclassification index 0.052, 95% confidence interval 0.012–0.091, P = 0.009; integrated discrimination index 0.020, 95% confidence interval 0.001–0.039, P = 0.051).ConclusionThe incidence of hospital-acquired VTE in patients with cardiovascular diseases is relatively low. The nomogram exhibits high accuracy in predicting hospital-acquired VTE in patients with cardiovascular diseases.

The evolution of the Caprini score

The article is a narrative review of the literature that addresses the issues of individual risk assessment of hospital-acquired VTE using the Caprini score. It provides modern epidemiological data confirming the high medical and social significance of the problem of hospital venous thrombosis. The questions of the natural evolution of the Caprini score since the publication of the initial version in 1991 are discussed, a comparative analysis of the modifications of 2005, 2010 and 2013 is carried out, and the features of validation studies that have proven the superiority of the classical version of 2005 are discussed. Attention is paid to the problem of integrating the Caprini score into medical documentation with automation of the process of risk assessment and the appointment of preventive measures. The issue of heterogeneity of approaches to dividing patients into risk groups for developing VTE in accordance with the assessed scores is discussed separately; data from modern studies are presented confirming the existence of very high (9–10 points) and extremely high (≥11 points) risk groups that require an individual approach to prevention of thrombotic complications. Summary data are provided on the frequency of registration of VTE in accordance with Caprini scores in patients of various medical profiles based on a meta-analysis of 68 validation studies. The possibility of using patient-oriented questionnaires based on the Caprini score is discussed, which demonstrate high consistency with the original scale, but have not yet been studied in prospective studies. Revised algorithms are proposed to individually assess the risk of VTE using the 2005 vers of the Caprini score and prescribe adequate prophylaxis. It is concluded that the Caprini score still continues to improve and evolve in accordance with general trends in the development of medicine and healthcare, while maintaining the status of the most studied and in demand system for individual assessment of the risk of developing hospital-acquired VTE.

Association of pharmacologic thromboprophylaxis with clinically relevant bleeding and hospital-acquired anemia in medical inpatients: the risk stratification for hospital-acquired venous thromboembolism in medical patients study

BackgroundPharmacologic thromboprophylaxis (pTPX) might exacerbate the risk of clinically relevant bleeding (CRB) and hospital-acquired anemia (HAA) in older multimorbid inpatients. ObjectivesWe aimed to evaluate the association of pTPX use with CRB and HAA. MethodsWe used data from a prospective cohort study conducted in 3 Swiss university hospitals. Adult patients admitted to internal medicine wards with no therapeutic anticoagulation were included. pTPX use was ascertained during hospitalization. Outcomes were in-hospital CRB and HAA. We calculated incidence rates by status of pTPX. We assessed the association of pTPX with CRB using survival analysis and with HAA using logistic regression, adjusted for infection, length of stay, and the International Medical Prevention Registry on Venous Thromboembolism bleeding risk score. ResultsAmong 1305 patients (mean age, 63.7 years; 44% women, 90% at low risk of bleeding), 809 (62%) received pTPX. The incidence of CRB was 2.4 per 1000 patient-days and was not significantly higher in patients with pTPX than in those without. We found no significant association between pTPX and CRB. HAA was frequent (20.2%) and higher in patients with pTPX than in those without (23.2% vs 15.3%). The incidence of HAA was 21.2 per 1000 patient-days and did not significantly differ between patients with pTPX and those without. We found an association between pTPX and HAA (adjusted odds ratio, 1.4; 95% CI, 1.0-2.1). ConclusionOur study confirmed the safety of pTPX in medical inpatients at low risk of bleeding but identified an association between pTPX and HAA. Adherence to guidelines that recommend administering pTPX to medical inpatients at increased venous thromboembolism risk and low bleeding risk is necessary.

Multicenter Study of a Risk Prediction Model for Critically Ill Children at High-Risk for Hospital-Acquired Venous Thromboembolism: Findings from the Children's Hospital-Acquired Thrombosis (CHAT) Consortium

Introduction: Critically ill children are at high-risk of developing a hospital-acquired venous thromboembolism (HA-VTE) as well as being at an increased risk for bleeding. To better understand which subset of children may benefit from thromboprophylaxis measures, (without contraindications for potential associated hemorrhagic complications), the Children's Hospital Acquired Thrombosis (CHAT) Consortium previously derived a HA-VTE risk assessment model (RAM) for critically ill children from 8 centers. This RAM included five variables: (1) immobility defined using a Braden score ≤2, (2) length of hospitalization prior to PICU admission, (3) central venous catheterization, (4) presence of congenital heart disease (CHD) and (5) history of autoimmune/inflammatory disorder or infection. For this study we aimed to externally evaluate our previous HA-VTE RAM in critically ill children in an independent cohort via the CHAT Consortium. Methods: Critically ill children aged 0-21 years admitted or transferred into a pediatric intensive care unit (PICU) at 32 U.S. centers were randomly selected to be enrolled in the study. Participants with a HA-VTE at admission or cardiac surgery within 2 weeks of PICU admission/transfer were excluded. Participants were prospectively followed via chart review for the development of a HA-VTE throughout their hospitalization and up to 30 days post discharge. Twenty-one variables that had been evaluated in univariate analyses from the previously-reported ICU-RAM derivation study were again analyzed in the present prospective cohort via univariate logistic regression. Variables with P-value of &amp;lt;0.1 were included in a multivariable logistic regression model, with P-values of &amp;lt;0.05 considered significant. Missing values were not imputed and complete case analysis was utilized. Results: From January 2020 to July 2022, 4,504 participants were enrolled and 93 developed a HA-VTE (2.1%). Complete data were available for 65 HA-VTE cases and 3056 controls without HA-VTE. Median age for HA-VTE participants was 5.2 years (interquartile range [IQR] 1.0-15.2) compared to 6.6 years (IQR 1.7-13.8) for those without HA-VTE; 55% and 53% of each group, respectively, were males. Among seven variables that met criteria for evaluation in the updated multivariable model, central venous catheter (odds ratio [OR] 4.2, 95% confidence interval [CI] 2.4-7.4), cancer (OR 3.1, 95% CI 1.4-6.7), immobility (OR 2.0, 95% CI 1.2-3.4, prior hospitalization (OR 2.0, 95% CI 1.1-3.5) and mechanical ventilation (OR 1.9, 95% CI 1.1-3.4) were each independently associated with HA-VTE risk (Table 1). The validation RAM had an area under the receiver operating characteristic curve of 0.81 (95% CI, 0.75-0.86) (Figure 1), compared to 0.78 (95% CI=0.73-0.84) for the previous model. Conclusions: The present work represents the largest external validation study of a HA-VTE RAM to date in critically ill children. We identified five independent risk factors for HA-VTE for children admitted to a PICU. Two of these factors were identified in the derivation study RAM, while three (cancer, prior hospitalization, and mechanical ventilation) were newly identified via this validation study.

Inflammation Sub-Group Analysis in Pediatric HA-VTE Cases: A Report from the Children's Hospital Acquired Thrombosis Registry (CHAT) Registry

Introduction: Hospital-Acquired venous thromboembolism (HA-VTE) is becoming an increasingly more common complication in children that may result in mortality, short- and long-term morbidity, and increased healthcare costs. To inform HA-VTE risk mitigation strategies, clinical research efforts have been undertaken to determine the precipitating causes of pediatric HA-VTE. Many of these studies have identified inflammation as an important underlying risk factor. We aimed to determine the association between HA-VTE and any clinical inflammatory state among a hospitalized pediatric patient population within the Children's Hospital Acquired Thrombosis (CHAT) Registry, with the hypothesis that inflammation increases the risk of HA-VTE among hospitalized children. Methods: Institutional review boards at all centers approved the protocol. Children aged 0-21 years admitted to a hospital at one of 8 U.S. pediatric healthcare institutions centers were enrolled in the study. Participants with VTE at admission were excluded. Electronic health records for enrolled subjects were reviewed for the development of a HA-VTE throughout their hospitalization and up to 30 days post discharge to identify cases. Control subjects were hospitalized patients without VTE on admission, during their hospital stay, or within 30 days of discharge. Controls were matched to cases by admission year and admitting institution. Acute inflammation was defined as notation of an inflammatory disease diagnosis (as defined by consensus of the physicians on the study team) as an admitting or discharge diagnosis but not in past medical history (PMH). Inflammatory disease diagnosis in PMH but not in admission/discharge diagnosis was denoted as chronic inflammation. Acute on chronic inflammation was identified in subjects having inflammatory disease diagnoses in both the PMH and admission/discharge diagnosis, while subjects without inflammation had no inflammatory diseases in either PMH or admission/discharge diagnoses. Inflammation was further categorized by consensus of the physicians on the study team as either systemic, regional, or local based on degree of organ system involvement. Results: From January 1, 2012 to December 31, 2021, 2164 subjects were enrolled. Complete data were available for 1218 HA-VTE cases and 946 controls. Median age for HA-VTE cases was 2.1 years compared to 5.8 years for controls without HA-VTE, with 56% of cases and 51% of controls being males. Cases were more likely than controls to have had surgery, ICU admission/transfer, intubation with mechanical ventilation, and central venous catheter placement, as well as to have received mechanical, pharmacological, or combined thromboprophylaxis while hospitalized. Among controls, 24 (2.5%) carried PMH diagnoses of inflammatory diseases, while 47 (3.9%) of the HA-VTE cases did (p=0.087). Among cases, 643 (52.8%) had infections either present on admission or develop while hospitalized, compared to 178 (18.8%) of controls (p&amp;lt;0.01). Steroids were administered to 677 (55.6%) of cases compared to 276 (29.2%) of controls (p&amp;lt;0.01). Interestingly, 42.5% of cases and 55.6% of controls were noted to exhibit any type of inflammation (p&amp;lt;0.01), while 39.2% of cases demonstrated systemic inflammation compared to only 26.5% of controls (p&amp;lt;0.01). Of the 1043 children with inflammation, systemic inflammation yielded an odds ratio (OR) of 1.78 (95% confidence interval [CI], 1.37-2.32) for HA-VTE development in univariate analysis. Four hundred eighty-six (39.9%) HA-VTE cases exhibited acute inflammation, 16 (1.3%) had chronic, 31 (2.6%) had acute-on-chronic, and 685 (56.2%) had no inflammation, compared to 513 (54.2%), 11 (1.2%), 13 (1.4%), and 409 (43.2%) for controls, respectively. Compared to no inflammation, acute-on-chronic inflammation demonstrated increased risk for HA-VTE development with OR 1.42 (95% CI 0.74-2.75). Conclusion: The present work demonstrates the importance of clinical inflammation subcategories when determining HA-VTE risk. Initial analysis of these data demonstrated that systemic inflammation, especially of the acute-on-chronic variety, conveys the highest risk for HA-VTE in children. Ongoing work will determine how to incorporate these concepts into clinical practice as well as clinical trials of HA-VTE prevention in children.

Development and validation of a risk model for hospital-acquired venous thrombosis: the Medical Inpatients Thrombosis and Hemostasis study

BackgroundRegulatory organizations recommend assessing hospital-acquired (HA) venous thromboembolism (VTE) risk for medical inpatients. ObjectivesTo develop and validate a risk assessment model (RAM) for HA-VTE in medical inpatients using objective and assessable risk factors knowable at admission. MethodsThe development cohort included people admitted to medical services at the University of Vermont Medical Center (Burlington, Vermont) between 2010 and 2019, and the validation cohorts included people admitted to Hennepin County Medical Center (Minneapolis, Minnesota), University of Michigan Medical Center (Ann Arbor, Michigan), and Harris Health Systems (Houston, Texas). Individuals with VTE at admission, aged <18 years, and admitted for <1 midnight were excluded. We used a Bayesian penalized regression technique to select candidate HA-VTE risk factors for final inclusion in the RAM. ResultsThe development cohort included 60 633 admissions and 227 HA-VTE, and the validation cohorts included 111 269 admissions and 651 HA-VTE. Seven HA-VTE risk factors with t statistics ≥1.5 were included in the RAM: history of VTE, low hemoglobin level, elevated creatinine level, active cancer, hyponatremia, increased red cell distribution width, and malnutrition. The areas under the receiver operating characteristic curve and calibration slope were 0.72 and 1.10, respectively. The areas under the receiver operating characteristic curve and calibration slope were 0.70 and 0.93 at Hennepin County Medical Center, 0.70 and 0.87 at the University of Michigan Medical Center, and 0.71 and 1.00 at Harris Health Systems, respectively. The RAM performed well stratified by age, sex, and race. ConclusionWe developed and validated a RAM for HA-VTE in medical inpatients. By quantifying risk, clinicians can determine the potential benefits of measures to reduce HA-VTE.

Model-Guided Decision-Making for Thromboprophylaxis and Hospital-Acquired Thromboembolic Events Among Hospitalized Children and Adolescents

Rates of hospital-acquired venous thromboembolism (HA-VTE) are increasing among pediatric patients. Identifying at-risk patients for whom prophylactic interventions should be considered remains challenging. To determine whether use of a previously validated HA-VTE prognostic model, together with pediatric hematologist review, could reduce pediatric inpatient rates of HA-VTE. This pragmatic randomized clinical trial was performed from November 2, 2020, through January 31, 2022, at a single-center academic children's hospital (Monroe Carell Jr Children's Hospital at Vanderbilt). All pediatric hospital admissions (aged <22 years) under inpatient status were included and randomized. All patients had an HA-VTE probability automatically calculated daily, which was visible to the hematology research team for patients in the intervention group. Patients with an elevated risk (predicted probability ≥2.5%) underwent additional medical record review by the research team to determine eligibility for thromboprophylaxis. The primary outcome was rate of HA-VTE. Secondary outcomes included rates of prophylactic anticoagulation and anticoagulation-associated bleeding events. A total of 17 427 hospitalizations met eligibility criteria, were randomized, and were included in the primary analysis: patients had a median (IQR) age of 1.7 (0 to 11.1) years; there were 9143 (52.5%) female patients and 8284 (47.5%) male patients, and there were 445 (2.6%) Asian patients, 2739 (15.9%) Black patients, and 11 752 (67.4%) White patients. The 2 groups were evenly balanced in number (8717 in the intervention group and 8710 in the control group) and patient characteristics. A total of 58 patients (0.7%) in the control group and 77 (0.9%) in the intervention group developed HA-VTE (risk difference: 2.2 per 1000 patients; 95% CI, -0.4 to 4.8 per 1000 patients; P = .10). Recommendations to initiate thromboprophylaxis were accepted by primary clinical teams 25.8% of the time (74 of 287 hospitalizations). Minor bleeding events were rare among patients who received anticoagulation (3 of 74 [4.1%]), and no major bleeding events were observed during the study period. Among patients randomized to the control group, the model exhibited high discrimination accuracy (C statistic, 0.799, 95% CI, 0.725 to 0.856). In this randomized clinical trial of the use of a HA-VTE prognostic model to reduce pediatric inpatient rates of HA-VTE, despite the use of an accurate and validated prognostic model for HA-VTE, there was substantial reluctance by primary clinical teams to initiate thromboprophylaxis as recommended. In this context, rates of HA-VTE between the control and intervention groups were not different. Future research is needed to identify improved strategies for prevention of HA-VTE and to overcome clinician concerns regarding thromboprophylaxis. ClinicalTrials.gov Identifier: NCT04574895.

Reducing Pediatric Hospital-Acquired Venous Thromboembolism—Overcoming Challenges Using Quality Improvement

Reducing Pediatric Hospital-Acquired Venous Thromboembolism—Overcoming Challenges Using Quality Improvement