Hospital-acquired Venous Thromboembolism Research Articles

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

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

A multifaceted quality improvement intervention on venous thromboembolism prophylaxis compliance in hospitalized medical patients at a comprehensive cancer center.

Previous studies suggest that quality improvement initiatives focused on hospital-acquired venous thromboembolism have a positive impact on prescribing rates of venous thromboembolism prophylaxis, especially those that incorporate computerized changes. We conducted a quality improvement project to determine whether education and computerized prescriber order entry system changes affect venous thromboembolism prophylaxis compliance rates in hospitalized medical patients at a Comprehensive Cancer Center. Between 1 January 2021 and 31 January 2023, 37,739 non-surgical, adult patient encounters with a length of stay > 48 h were analyzed in our study. From 18 December 2021 to 8 March 2022, provider education was delivered to the three largest admitting services, and computerized prescriber order entry changes were implemented incorporating a mandatory requirement to either order venous thromboembolism prophylaxis or document a contraindication for all patients at moderate venous thromboembolism risk. Monthly venous thromboembolism prophylaxis compliance rates, as defined by the Centers for Medicare and Medicaid Services VTE-1 metric, increased from a mean of 74% to 93% after the interventions. This change was driven primarily by an increased utilization of mechanical venous thromboembolism prophylaxis from 37% to 53%. Our study demonstrated that a multi-faceted intervention incorporating provider education and computerized prescriber order entry system changes can significantly increase venous thromboembolism prophylaxis compliance rates in cancer patients.

PB1467 Hospital-Acquired (HA) versus Post-Discharge (PD) Venous Thromboembolism (VTE) Similarities and Differences: Analysis of the Medical Inpatient Thrombosis and Hemostasis (MITH) Population

PB1467 Hospital-Acquired (HA) versus Post-Discharge (PD) Venous Thromboembolism (VTE) Similarities and Differences: Analysis of the Medical Inpatient Thrombosis and Hemostasis (MITH) Population

Hospital Acquired Venous Thromboembolism: A Preventability Assessment.

Background: The American Heart Association has a call to action to reduce hospital acquired venous thromboembolism (HA-VTE) by 20% by the year 2030. There is increasing recognition that quality improvement initiatives for VTE reduction should focus on reducing potentially preventable HA-VTE. The objective of our study was to determine what proportion of HA-VTE events are potentially preventable. Methods: This was a retrospective, single center pilot study of 50 patients with HA-VTE. Seven preventability factors were identified with a focus on VTE prescription and administration. Data were extracted through chart review using a systematic data collection form. The primary endpoint was the proportion of patients with potentially preventable HA-VTE. Descriptive statistics were used. Results: The median age was 66 years with an admission VTE risk level of moderate-high in 94%. Potentially preventable HA-VTE was found in 40% of cases. Missed doses occurred in 29.8% with a median of 2 missed doses and a range of 1 to 20. Patient refusal was the most common reason for missed doses in 71%. Delays in initiation occurred in 12.7%. Sixty percent of those on mechanical prophylaxis only had nonadherence. Conclusion: Forty percent of HA-VTE cases were potentially preventable. Missed doses was the most common preventability factor identified with patient refusal accounting for most missed doses.

1263 Venous Thromboembolism (VTE) Risk Assessment and Thromboprophylaxis Among Hospitalised Patients: A Single-Centre Closed Loop Audit

Abstract Aim With an estimated incidence rate of 1 to 2 cases per 1,000 population, venous thromboembolism (VTE) remains a significant cause of morbidity and mortality in the United Kingdom. It is reported that VTE is responsible for approximately 60,000 deaths per annum. Furthermore, VTE has a huge financial impact on the NHS. It is reported that VTE treatment costs the NHS approximately £640 million every year. Notably, at least two-thirds of hospital-acquired VTE are preventable. NICE guideline recommends that all patients should be risk-assessed on admission and re-assessed at the point of consultant review [NG89]. The purpose of this closed-loop audit was to evaluate the effectiveness of simple interventions in improving the efficiency of VTE risk assessments at a large teaching hospital. Method Results from the first cycle were analysed and interventions were implemented with the aim to improve the standard of practice. These include the utilisation of technology in VTE risk assessments, mandatory teaching sessions and the development of prompts within clerking proformas. A repeat audit was subsequently performed to re-assess the new standard of practice and the effectiveness of these interventions. Results Our VTE risk assessment completion rates increased substantially from 16.67% to 100% and the median time taken to complete VTE risk re-assessments also improved notably from 97 to 21 hours. Positive feedbacks have been received on the effectiveness of these interventions. Conclusions By implementing these simple interventions, we can see a substantial improvement in the standards of VTE risk assessments, in compliance with the NHS Standard Contract and NICE guidelines.

Cohort profile for development of machine learning models to predict healthcare-related adverse events (Demeter): clinical objectives, data requirements for modelling and overview of data set for 2016–2018

PurposeIn-hospital health-related adverse events (HAEs) are a major concern for hospitals worldwide. In high-income countries, approximately 1 in 10 patients experience HAEs associated with their hospital stay. Estimating the risk...

Hospital-acquired venous thromboembolism during invasive mechanical ventilation in children: a single-center, retrospective cohort study

BackgroundInvasive mechanical ventilation (IMV) has been independently associated with hospital-acquired venous thromboembolism (HA-VTE) among critically ill children, including extremity deep venous thrombosis and pulmonary embolism. ObjectivesWe aimed to characterize the frequency and timing of HA-VTE following IMV exposure. MethodsThis was a single-center, retrospective cohort study including children aged <18 years, hospitalized in a pediatric intensive care unit, undergoing mechanical ventilation for >24 hours from October 2020 through April 2022. Encounters with an existing tracheostomy or receiving treatment for HA-VTE prior to endotracheal intubation were excluded. The primary outcomes characterized clinically-relevant HA-VTE, including timing after intubation, location, and the presence of known hypercoagulability risk factors. Secondary outcomes were IMV exposure magnitude, defined by IMV duration and ventilator parameters (ie, volumetric, barometric, and oxygenation indices). ResultsOf 170 consecutive, eligible encounters, 18 (10.6%) experienced HA-VTE at a median of 4 days (IQR, 1.4-6.4) following endotracheal intubation. Those with HA-VTE had an increased frequency of a prior venous thromboembolism (27.8% vs 8.6%, P = .027). No differences in frequency of other HA-VTE risk factors (ie, acute immobility, hematologic malignancy, sepsis, and COVID-19–related illness), presence of a concurrent central venous catheter, or the magnitude of IMV exposure were noted. ConclusionChildren undergoing IMV experience HA-VTE at markedly higher rates than previously estimated in the general pediatric intensive care unit population after endotracheal intubation. While prospective validation is needed, these findings are an important step toward informing the development of risk-stratified thromboprophylaxis trials in critically ill children.

Evaluation of venous thromboembolism risk factors reveals subtype heterogenicity in children with central venous catheters: a multicenter study from the Children’s Hospital Acquired Thrombosis consortium

BackgroundAcutely ill and medically complex children frequently rely on central venous catheters (CVCs) to provide life-sustaining treatment. Unfortunately, catheter-related thrombosis (CRT) is a serious and common complication. Little is known why some with a CVC develop CRT and others develop venous thromboembolism unrelated to the CVC (non-CRT). ObjectivesThe aim of this study was to identify factors associated with CRT in children with hospital-acquired venous thromboembolism (HA-VTE). MethodsThis case-case study included participants in the Children’s Hospital Acquired Thrombosis Registry with HA-VTE and CVC aged 0 to 21 years from 8 US children’s hospitals. Participants were excluded if they developed HA-VTE prior to CVC insertion or if the CVC insertion date was unknown. Logistic regression models were used to assess associations between clinical factors and CRT status. ResultsThere were 1144 participants with HA-VTE who had a CVC. CRT developed in 833 participants, and 311 developed non-CRT. Multivariable analysis showed increased odds of CRT (compared with non-CRT) in participants with peripherally inserted central catheters (odds ratio [OR], 3.80; 95% CI, 2.04-7.10; p < .001), CVCs inserted in the femoral vein (OR, 4.45; 95% CI, 1.70-11.65; p = .002), multiple CVCs (OR, 1.42; 95% CI, 1.18-1.71; p < .001), and CVC malfunction (OR, 3.30; 95% CI, 1.80-6.03; p < .001). ConclusionThe findings of this study provide new insights on risk factor differences between CRT and non-CRT. Prevention efforts should be directed at modifying the type of CVC, insertion location, and/or number of CVCs placed, if possible, to decrease the incidence of CRT.

632: HOSPITAL-ACQUIRED VENOUS THROMBOEMBOLISM AMONG CHILDREN UNDERGOING INVASIVE MECHANICAL VENTILATION

Introduction: Hospital-acquired venous thromboembolism (HA-VTE) has an incidence of 2.2% among critically ill children. Although risk factors have been described (e.g., immobility, central venous catheterization [CVC], and systemic inflammation), insufficient data exists to recommend routine thromboprophylaxis (TP) in the pediatric intensive care unit (PICU). Children undergoing mechanical ventilation (MV) may represent an at-risk population due to illness severity, intentional immobility, and frequent CVC presence. We sought to estimate the rate and timing of HA-VTE for children undergoing MV and explore for variation in HA-VTE rates by MV parameters. Methods: We performed a single-center, retrospective cohort study of children < 18 years of age in the PICU undergoing MV from October 2020 - March 2022 excluding those with tracheostomy, HA-VTE prior to MV, and a total MV exposure of < 24 hours. The primary outcome was HA-VTE identified after intubation confirmed by imaging. Secondary outcomes were HA-VTE characteristics (i.e., timing, location, and CVC-related), MV parameters (i.e., barometric, volumetric, and compliance data within 72-hours of intubation), and other known HA-VTE risk factors. Descriptive and comparative statistics (Fisher’s exact, Wilcoxon rank sum, and Student’s t tests) were employed. Results: Of 170 subjects studied, 18 (10.6%) developed a HA-VTE (limb deep venous thromboses) at median of 4 (interquartile range [IQR]:1.4,6.4) days after intubation. Those with HA-VTE had a greater frequency of comorbid CVC (88.9% vs 61.8%, P=0.034) and prior history of HA-VTE (27.8% vs 8.6%, P=0.027). No differences in demographics, anthropometrics, severity of illness indices, immobility, applied TP, rates of comorbid hematologic malignancy, sepsis, COVID-19, trauma, or postoperative admission were noted. No differences were observed for rates of conventional MV, high-frequency oscillation, intubation timing, or MV duration. Ventilator parameters were not different between those with and without HA-VTE. Conclusions: In our study, the rate of HA-VTE among critically ill children undergoing MV was 10.6% and more common to children with comorbid CVC. Although HA-VTE rates were not observably different by MV exposure, duration, or intensity, prospective studies are still required.

Venous Thromboembolism Prophylaxis in High-Risk Pediatric Oncology Patients

Introduction Pediatric oncology patients are at increased risk for hospital-acquired venous thromboembolism (HA-VTE), which is associated with increased morbidity in this population. Up to 20% of pediatric oncology patients with central venous catheters (CVC) experience HA-VTE. However, much debate exists over the use of pharmacologic thromboprophylaxis to prevent HA-VTE in the pediatric oncology population, primarily due to lack of evidence regarding safety and efficacy. Pediatric oncology patients have many well-established risk factors for VTE including adolescence, obesity, CVC presence, and receipt of asparaginase chemotherapy. Given the uncertainty regarding prevention strategies in this population, research is needed regarding the use of prophylactic anticoagulation in pediatric oncology patients. Objective: To evaluate the use of prophylactic anticoagulation in pediatric oncology patients at risk for HA-VTE. Methods A retrospective, single center chart review of pediatric oncology patients who received clinical care at a tertiary care children's hospital was performed. Over 1600 patients were captured from a departmental database of all new oncologic diagnoses identified between January 1, 2014 and December 31, 2014. Patients were excluded if they received care at another institution or did not have an additional risk factor for HA-VTE outside of cancer diagnosis. Defined risk factors were age >12 years, body mass index (BMI) >30, CVC placement, receipt of asparaginase, and history of thrombosis. 514 patients met inclusion criteria. Patient age, BMI, history of thrombophilia, type of CVC, cancer type, steroid administration and asparaginase administration were analyzed as potential risk factors for VTE. Logistic regression was used to model odds of thrombus as a function of risk factors. A classification and regression tree (CART) model was also fitted to identify predictors of thrombus. Results Of 514 patients identified as high-risk for VTE, only 19 (3.7%) received prophylaxis. Most patients received enoxaparin for prophylaxis. Almost 15% (75/514) developed VTE during the study period. Of those who developed a VTE, 9% (7/75) were on prophylaxis at the time of VTE. 100% of the patients that developed VTE had a CVC in place. Obese patients were most likely to develop VTE with an odds ratio of 2.2 (95% CI 1-4.3, p 0.032). 28% (18/65) of obese patients developed VTE, yet only 6% (4/65) of obese patients received prophylaxis. Of these obese patients, 50% (2/4) developed VTE despite prophylaxis. Patients age >12 years were more likely to have VTE than those age <12 years (OR 1.1; 95% CI 1-1.1, p 0.023). Patients with Hickman catheters also had twice the odds of developing VTE (OR 2.1; 95% CI 1-4.1, p 0.046). In evaluating VTE occurrence by malignancy type, patients with hepatic tumors had the highest occurrence of thrombosis (8/12; 87%) followed by patients with myeloid leukemia (10/36; 28%), and lymphoblastic leukemia (28/170; 16%). The CART model was able to accurately predict occurrence or non-occurrence of thrombus in 87% of patients in the dataset based on the risk factors of obesity, age, and cancer type. Discussion It is well-established that malignancy is a significant risk factor for the development of VTE in pediatric oncology patients. Yet due to concern for bleeding events in these patients who frequently have thrombocytopenia, pharmacologic prophylaxis may not be used despite additional high-risk factors for VTE. This study demonstrates that pharmacologic prophylaxis is rarely used, even among high-risk pediatric oncology patients. For each risk group, most patients prescribed prophylaxis did not develop thrombus, however VTE still occurred in some. Risk stratification for pediatric oncology patients is essential given potential bleeding risk. We were able to identify additional high-risk features such as obesity, type of CVC, and cancer type. The CART model for high-risk pediatric populations had high specificity (88%) but poor sensitivity (23%). Application of this model could inform appropriate use of thromboprophylaxis in pediatric oncology patients to reduce the incidence of HA-VTE in this population. Further research is needed regarding safety and efficacy of prophylaxis, but this study provides important data to guide future steps.

Anticoagulation Use for Secondary Prophylaxis Against Recurrent Venous Thromboembolism in Hospitalized Children: A Report from the Children's Hospital-Acquired Thrombosis (CHAT) Consortium

Introduction: Most venous thromboembolism (VTE) in children are provoked and have an overall low risk for recurrence, especially if the original provoking factor is mitigated. Nonetheless, certain factors heighten VTE recurrence risk, including hospitalization. In fact, the rate of VTE in hospitalized children has increased more than 200% since 20011. This staggering discovery emphasizes the dire need for more effective tactics aimed at VTE prevention. Historically, pediatric providers have been hesitant to initiate pharmacologic (i.e. anticoagulant) measures in children for a number of reasons. In our recent survey of practice patterns of secondary prevention against recurrent VTE in pediatrics, we found low use (<25%) of pharmacologic prophylaxis in high-risk children2. Additionally, most respondents did not feel comfortable initiating secondary pharmacologic prophylaxis in younger children2. In the wake of the COVID-19 pandemic, numerous trials have been conducted to evaluate anticoagulation for VTE prevention in affected individuals. The recently published COVID-19 Anticoagulation in Children- Thromboprophylaxis trial showed safety of low-dose enoxaparin in children hospitalized with COVID-19 or multisystem inflammatory syndrome in children (MIS-C)3. Furthermore, trials of direct oral anticoagulants have also shown safety and efficacy in secondary VTE prevention in children4. Importantly, these studies have consistently demonstrated low rates of bleeding. Methods: The CHAT Registry is an IRB-approved registry that captures clinical data on hospital-acquired VTE in children <21 years of age and non-VTE controls. Subjects were enrolled from 2012-2021 across 8 participating pediatric hospitals. Using this REDCap database, we performed a retrospective study of enrolled subjects to explore trends for secondary anticoagulation prophylaxis use in hospitalized children. Subjects (cases and controls) were included if they had a history of VTE. Descriptive statistics were used to analyze demographics/characteristics and VTE prophylaxis measures. Results: Fifty-two subjects (%) out of 2219 total CHAT subjects (1273 cases, 946 controls) reviewed had a prior history of VTE. Characteristics of these subjects are presented in Table 1. The mean age was 9.6 years with a slight male predominance (54%). Regarding VTE prophylaxis (Figure 1), 18 (35%) received VTE prophylaxis (mechanical and/or pharmacologic) during hospitalization. Of these, 11 subjects (61%) were prescribed pharmacologic prophylaxis either alone (8) or in combination with mechanical prophylaxis (3). The remaining seven (39%) received only mechanical prophylaxis. Four subjects were already on anticoagulation at the time of admission. Forty-four (85%) subjects experienced a hospital-acquired VTE recurrence. Only 16 (36%) of these had received some method of VTE prophylaxis. Of those who did not receive pharmacologic prophylaxis, only 3 had a documented contraindication. The most commonly documented contraindications to pharmacologic prophylaxis pertained to risk of bleeding, and included uncorrected coagulopathy, ongoing/uncontrolled hemorrhage and thrombocytopenia. The median time between admission and VTE event was 9 days. Conclusion: There is a high rate of recurrent VTE in hospitalized children with a history of prior VTE. These results underscore the significance of implementing consistent pharmacologic prophylaxis in high-risk children where appropriate. As the landscape is actively changing in terms of available anticoagulant formulations available for children, providers may feel more confident in initiating secondary pharmacologic prophylaxis particularly as new data confirm the safety. Nevertheless, ongoing definitive studies are required to better understand which particular factors yield the highest rates of VTE and hence warrant pharmacologic prophylaxis above standard mechanical measures. We want to acknowledge the CHAT Consortium sites who contributed to the CHAT Registry. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Risk factors for hospital acquired venous thromboembolism in congenital heart disease patients: A report from the children's hospital acquired thrombosis (CHAT) consortium

IntroductionThe incidence of pediatric hospital-acquired venous thromboembolism (HA-VTE) has increased over time. Congenital heart disease (CHD) as a co-morbidity has been demonstrated to significantly increase HA-VTE risk among hospitalized children. ObjectiveTo identify specific risks factors for the development of HA-VTE in hospitalized children with CHD. Materials and methodsThis retrospective case-control study included hospitalized participants aged 0–21 years within the Children's Hospital Acquired Thrombosis (CHAT) Consortium Registry with a co-morbidity of CHD. Participants with HA-VTE and non-VTE controls with a past medical history of CHD were selected from the CHAT Registry and data regarding multiple clinical variables were extracted. These variables were then analyzed to assess their association with HA-VTE development. ResultsThree hundred and thirty-three participants with a co-morbidity of CHD were identified, comprising 275 HA-VTE cases and 58 controls. Median age for HA-VTE cases was 0.4 (IQR = 0–2.6) years compared to 3.4 (IQR = 0.7–6.5) for controls. Male participants were predominant in both groups (57.5 % HA-VTE cases vs 51.7 % controls). Multivariable analysis identified prior recent hospitalization (OR = 4.12, 95%CI = 1.66–10.24), intensive care unit (ICU) admission (OR = 3.29, 95 % CI = 1.15–9.40), and CVC placement (OR = 9.14, 95 % CI = 3.38–24.72) as significant risk factors for HA-VTE in subjects with CHD. ConclusionsICU admission, CVC placement, and prior hospitalization were identified as statistically significant predictors associated with HA-VTE development in hospitalized children with history of CHD. Prospective studies are needed to validate these results and help develop strategies to mitigate HA-VTE development in these patients.

Risk of venous thromboembolism in pediatric hospitalized patients undergoing noncardiac surgery: A report from the Children's Hospital‐Acquired Thrombosis consortium

BackgroundSurgery is a known risk factor for hospital‐acquired venous thromboembolism (HA‐VTE) in children. ObjectivesTo assess whether the odds of HA‐VTE differs across six anatomic sites of noncardiac surgery and to identify risk factors for HA‐VTE in these children. Methodswas a multicenter, case–control study. Anatomic sites of surgery and risk factors for HA‐VTE were collected on hospitalized pediatric patients who had undergone a single noncardiac surgery and developed HA‐VTE (cases), and those who did not develop HA‐VTE (controls), via the Children's Hospital‐Acquired Thrombosis (CHAT) Registry. Logistic regression estimated the odds ratio (OR) and 95% confidence intervals (CIs) between six anatomic sites of surgery and 16 putative HA‐VTE risk factors. Variables with a p value of 0.10 or less in unadjusted analyses were included in adjusted models for further evaluation. The final model used backward selection, with a significance level of 0.05. ResultsFrom January 2012 to March 2020, 163 cases (median age, 5.7 years; interquartile range [IQR], 0.3–14.2) and 208 controls (median age of 7.5 years; IQR, 3.7–12.9) met our criteria. There was no statistically significant increased odds of VTE among the types of noncardiac surgery. In the final adjusted model, central venous catheter (CVC; OR, 14.69; 95% CI, 7.06–30.55), intensive care unit (ICU) stay (OR, 5.31; 95% CI, 2.53–11.16), and hospitalization in the month preceding surgery (OR, 2.75; 95% CI, 1.24–6.13) were each independently significant risk factors for HA‐VTE. ConclusionIn children undergoing noncardiac surgery, placement of CVCs, admission/transfer to the ICU, or hospitalization in the month prior to surgery were positively associated with HA‐VTE.

Current practices in pediatric hospital‐acquired thromboembolism: Survey of the Children's Hospital Acquired Thrombosis (CHAT) Consortium

BackgroundA rise in hospital‐acquired venous thromboembolism (HA‐VTE) in children has led to increased awareness regarding VTE prophylaxis and risk assessment. Despite no consensus exists regarding these practices in pediatrics. ObjectiveTo describe common practices in VTE prophylaxis, VTE risk assessment models, and anticoagulation dosing strategies in pediatric hospitals that are members of the Children's Hospital Acquired Thrombosis (CHAT) Consortium. MethodsAn electronic survey of 44 questions evaluating practices surrounding pediatric HA‐VTE risk assessment and prevention was distributed between August 9, 2021, and August 30, 2021, to the primary investigators from the 32 institutions within the CHAT Consortium. ResultsThe survey response rate was 100% (n = 32). In total, 85% (n = 27) of the institutions assess HA‐VTE, but only 63% (n = 20) have formal hospital guidelines. Within the institutions with formal guidelines, 100% (n = 20) include acute systemic inflammation or infection and presence of a central venous catheter (CVC) as risk factors for VTE. Pharmacologic prophylaxis is prescribed at 87% (28) of institutions, with enoxaparin being the most frequent (96%, n = 27). Variability in responses persisted regarding risk factors, risk assessment, thromboprophylaxis, dosing of prophylactic anticoagulation or anticoagulant drug monitoring. A majority of providers were comfortable providing thromboprophylaxis across all age groups. In addition, the global coronavirus disease 2019 increased the providers' use of prophylactic anticoagulation 78% (n = 25). ConclusionPractices among institutions are variable in regard to use of HA‐VTE prophylaxis, risk assessment, or guideline implementation, highlighting the need for further research and a validated risk assessment model through groups like the CHAT Consortium.

Predictive Ability of the Braden QD Scale for Hospital-Acquired Venous Thromboembolism in Hospitalized Children.

Hospital-acquired venous thromboembolisms (HA-VTEs) are increasingly common in pediatric inpatients and associated with significant morbidity and cost. The Braden QD Scale was created to predict the risk of hospital-acquired pressure injury (HAPI) and is used broadly in children's hospitals. This study evaluated the ability of the Braden QD Total score to predict risk of HA-VTE at a quaternary children's hospital. To analyze the predictive potential of the Braden QD Total score and subscores for HA-VTEs, the researchers performed univariate logistic regressions. The increase in a patient's odds of developing an HA-VTE for every 1-point increase in each Braden QD score was evaluated. Each model was evaluated using a 5-fold cross-validated area-under-the-curve of the corresponding receiver operating characteristic curve (AUROC). This study analyzed 27,689 pediatric inpatients. HA-VTE occurred in 135 patients. The odds of HA-VTE incidence increased by 29% (odds ratio 1.29, 95% confidence interval [CI] 1.25-1.34, p < 0.001) for every 1-point increase in a patient's Braden QD Total score. The AUROC was 0.81 (95% CI 0.77-0.85). The Braden QD Scale is a predictor for HA-VTE, outperforming its original intended use for predicting HAPI and performing similarly to other HA-VTE predictive models. As the Braden QD Total score is currently recorded in the electronic health records of many children's hospitals, it could be practically and easily implemented as a tool to predict which patients are at risk for HA-VTE.

Preventability of venous thromboembolism in hospitalised patients.

Hospital-acquired venous thromboembolism (VTE) is a major cause of morbidity and mortality. To determine the proportion of patients with hospital-acquired VTE that are preventable. This was a retrospective study of patients in two tertiary care hospitals in Sydney, Australia. Data were collected for patients with hospital-acquired VTE based on International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification (ICD-10-AM) coding from January 2018 to May 2020. Patients were classified as low, moderate or high risk of developing a VTE during hospitalisation based on demographic and clinical factors. A hospital-acquired VTE was considered to be potentially preventable if there was suboptimal prophylaxis in the absence of contraindications. Suboptimal therapy included at least one of the following related to VTE prophylaxis: low dose, missed dose (prior to developing a VTE), suboptimal drug and delayed start (>24 h from admission). There were 229 patients identified with VTE based on ICD-10-AM coding. A subset of 135 patients were determined to have actual hospital-acquired VTE. Of these, there were no patients at low risk, 64% (87/135) at moderate risk and 44% (48/135) at high risk of developing a VTE. Most (65%; n = 88/135) patients had one or more contraindications to receive recommended prophylaxis. Overall, the proportion of patients who received suboptimal prophylaxis was 11% (15/135). Approximately one out of 10 hospital-acquired VTE are preventable. Hospitals should focus on measuring and reporting VTE that are preventable to provide a more accurate measure of the burden of VTE that can be reduced by improving care.

Outcomes of Prophylactic Enoxaparin Against Venous Thromboembolism in Hospitalized Children

To assess the biochemical and clinical outcomes of hospitalized children who received prophylactic enoxaparin. We conducted a retrospective observational study of hospitalized children aged <18 years who received prophylactic enoxaparin against hospital-acquired venous thromboembolism (HA-VTE). Weight-based enoxaparin dosing was administered using a pharmacy-driven protocol, which later included a low molecular weight, anti-Xa level directed-dose adjustment strategy. Primary biochemical and clinical outcomes were achievement of goal anti-Xa range of 0.2 to 0.5 IU/mL and development of HA-VTE, respectively. Secondary clinical outcome was development of clinically relevant bleed. We analyzed 194 children with 13 (6.7%) infants aged <1 year and 181 (93.3%) older children aged ≥1 year. After the initial dose, only 1 (11.1%) infant, but 62 (57.9%) older children, achieved goal. Median number of anti-Xa levels until goal was 2 (interquartile range: 2-3) in infants and 1 (interquartile range: 1-2) in older children (P = .01). HA-VTE developed in 2 (15.4%) infants and 9 (5.0%) older children. Among children with anti-Xa level, HA-VTE developed less frequently in children who achieved (2.1%) than in those who did not achieve (13.6%) goal (P = .046). A total of 4 (2.1%) older children and no infants developed clinically relevant bleed. Among children with anti-Xa level, frequency of bleeding was comparable between children who did (3.2%) and did not achieve (0%) goal (P >.99). Our findings suggest the effectiveness and safety of an anti-Xa level directed strategy of prophylactic enoxaparin. However, this strategy should be investigated in prospective controlled studies.

The Association Between Time to First Dose of Venous Thromboembolism Prophylaxis and the Incidence of Hospital-Acquired Venous Thromboembolism.

The Association Between Time to First Dose of Venous Thromboembolism Prophylaxis and the Incidence of Hospital-Acquired Venous Thromboembolism.

A Snapshot of Venous Thromboembolism (VTE): Retrospective Audit of Events at a Metropolitan Tertiary Referral Hospital

BackgroundFacility-level review of hospital-acquired venous thromboembolism (HA-VTE) cases, including pulmonary embolism (PE) and deep vein thrombosis (DVT), can provide insight into the local drivers of this preventable complication.AimTo determine the nature of HA-VTE, patient characteristics, VTE risk assessment completion and appropriateness of prescribed VTE prophylaxis at a metropolitan tertiary referral hospital and to compare the number of HA-VTE detected by audit of imaging scans with those reported by clinical coding.MethodsWe conducted a retrospective electronic medical record audit encompassing all patients diagnosed with HA-VTE via ventilation-perfusion scan, computed tomographic pulmonary angiography and/or doppler ultrasound using a demographic and VTE risk assessment audit tool during selected months of 2017-2019. We compared the number of manually audited cases with the number of performance unit-coded cases for the same months.ResultsThe months of May 2017, October 2017, April to July 2018 and April to July 2019 were included. There was a significant difference between HA-VTE detected via manual audit (147 events) and hospital coding (18 events), p=0.002. Manual audit patients were majority non-surgical (65%), female (58%), over 60 years (80%), at moderate VTE risk (71%) with reduced mobility (52%). There were 108 DVT-only (73%), 23 PE-only (16%) and 16 DVT plus PE events (11%). Notable risk factors were moderate to major surgery (30%), active malignancy or cancer treatment (24%) and active infection (27%). Most patients were prescribed appropriate VTE prophylaxis (74%) and had documented VTE risk assessment (68%). Appropriate VTE prophylaxis was significantly associated with using an electronic clinical decision support tool during VTE risk assessment (p=0.024).ConclusionFacility-driven HA-VTE audits provide opportunity to developed targeted initiatives for at-risk patients at a local level. Greater numbers of HA-VTE identified via manual audit suggest the need for future real-time documentation of HA-VTE to assist with efficient case review. DisclosuresNo relevant conflicts of interest to declare.

Risk Assessing Medical Inpatients for Hospital-Acquired Venous Thrombosis: The Medical Inpatients Thrombosis and Hemostasis (MITH) Study

Introduction: Multiple regulatory agencies and professional societies recommend risk assessment of hospitalized medical patients for hospital-acquired (HA) venous thromboembolism (VTE) and provision of pharmacologic prophylaxis to those at risk. Extant risk assessment models (RAMs) include risk factors not knowable or difficult to assess at admission and often do not include risk factors reflecting illness acuity (such as laboratory studies and vital signs at admission). We developed a RAM for HA-VTE that reports absolute VTE risk, as opposed to arbitrary risk categories, using only objective risk factors measured within the first 24 hours of admission.Methods: The study setting was a combined academic and community 540-bed teaching hospital in northwest Vermont (The University of Vermont Medical Center). Using validated electronic health record (EHR) derived phenotypes (computable phenotypes), we captured all medical admissions between 2010-2019 and examined patient demographics, past medical history, and presenting vital and laboratory measures as potential risk factors for HA-VTE. As risk assessment should happen within 24 hours of admission, we only assessed risk factors knowable within this timeframe. Individuals with VTE at admission were excluded. Key outcome and risk factor definitions were validated using chart review. Bayesian logistic regression with a least absolute shrinkage and selection operator (LASSO) prior probability distribution was used to select risk factors for the model. Variables with a t-statistic ≥1.5 or ≤-1.5 were included in the final model. Full or prophylactic anticoagulation use was adjusted for in the final model. Model performance was assessed using bootstrap resampling to estimate area under the receiver operating characteristic (AUC) curve and calibration slope with 95% confidence interval (CI).Results: There were 62,468 medical admissions in the study period with 219 HA-VTE events. Chart review demonstrated the positive predictive value of our HA-VTE computable phenotype to be 84% and the negative predictive value 99%. Mean age was 65 years and 51% were male. Comorbid conditions were common in this hospitalized population, including active cancer (29%), congestive heart failure (25%), diabetes (27%), hypertension (59%), and prior myocardial infarction (13%). Seven risk factors met the criteria for inclusion in the final model: prior history of VTE (OR 2.7; 95% CI 1.8, 3.8), red cell distribution width ≥14.7% (OR 1.6; 95% CI 1.2, 2.2), creatinine ≥2.0 mg/dL or on dialysis (OR 2.0; 95% CI 1.4, 2.8), serum sodium <136 MEq/L (OR 1.5; 95% CI 1.1, 2.1), active cancer (OR 1.4; 95% CI 1.1, 2.0), malnutrition based on prior reported weight loss (OR 2.1; 95% CI 1.3, 3.3), and low hemoglobin (<13.6 g/dL in men, <12.1 g/dL in women; OR 1.5; 95% CI 1.0, 2.1). The unadjusted AUC of the RAM was 0.73 with an unadjusted calibration slope 1.09 (Figure 1). The optimism-adjusted AUC was 0.68 (95% CI 0.64, 0.71) and the optimism-adjusted calibration slope was 0.87 (95% CI: 0.72, 1.03).Discussion: We developed and internally validated a RAM for HA-VTE during medical hospitalization which incorporates simple, objective risk factors knowable within the first 24 hours of admission. Unlike most prior RAMs, this model also incorporates risk factors reflecting illness severity such as laboratory results. The RAM has good fit and calibration and will be moved forward to external validation. Future applications include incorporating the RAM into hospital admission workflows and assessing VTE prophylaxis rates and the incidence of HA-VTE and HA-bleeding. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.