Hospital-associated Venous Thromboembolism Research Articles

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.

Advances and current research in primary thromboprophylaxis to prevent hospital-associated venous thromboembolism.

Hospital-associated venous thromboembolism (VTE) is defined as any case of VTE occurring during hospital admission and for up to 90 days post discharge. It accounts for over 50% of all cases of VTE internationally; indeed, there are an estimated 10 million cases of hospital-associated VTE annually. Over the last decade, there has been increasing interest in improving VTE risk assessment and thromboprophylaxis. This review summarises all the recent and ongoing major research studies and future challenges in the different areas, including medical, surgical and obstetric patients, as well as special areas such as lower limb immobilisation. We include sections on both pharmacological and mechanical thromboprophylaxis.

Assessment of the CLOT (children's likelihood of thrombosis) real-time risk prediction model of hospital-associated venous thromboembolism in children with congenital heart disease

BackgroundChildren with congenital heart disease (CHD) are at high risk for hospital-associated venous thromboembolism (HA-VTE). The children's likelihood of thrombosis (CLOT) trial validated a real-time predictive model for HA-VTE using data extracted from the EHR for pediatric inpatients. We tested the hypothesis that addition of CHD specific data would improve model prediction in the CHD population. MethodsModel performance in CHD patients from 2010 to 2022, was assessed using 3 iterations of the CLOT model: 1) the original CLOT model, 2) the original model refit using only data from the CHD cohort, and 3) the model updated with the addition of cardiopulmonary bypass time, STAT Mortality Category, height, and weight as covariates. The discrimination of the three models was quantified and compared using AUROC. ResultsOur CHD cohort included 1457 patient encounters (median 2.0 IQR [0.5-5.2] years-old). HA-VTE was present in 5% of our CHD cohort versus 1% in the general pediatric population. Several features from the original model were associated with thrombosis in the CHD cohort including younger age, thrombosis history, infectious disease consultation, and EHR coding of a central venous line. Lower height and weight were associated with thrombosis. HA-VTE rate was 12% (18/149) amongst those with STAT Category 4-5 operation versus 4% (49/1256) with STAT Category 1-3 operation (P < .001). Longer cardiopulmonary bypass time (124 [92-205] vs. 94 [65–136] minutes, P < .001) was associated with thrombosis. The AUROC for the original (0.80 95% CI [0.75-0.85]), refit (0.85 [0.81-0.89]), and updated (0.86 [0.81-0.90]) models demonstrated excellent discriminatory ability within the CHD cohort. ConclusionThe automated approach with EHR data extraction makes the applicability of such models appealing for ease of clinical use. The addition of cardiac specific features improved model discrimination; however, this benefit was marginal compared to refitting the original model to the CHD cohort. This suggests strong predictive generalized models, such as CLOT, can be optimized for cohort subsets without additional data extraction, thus reducing cost of model development and deployment.

Effectiveness, Safety, and Costs of Thromboprophylaxis with Enoxaparin or Unfractionated Heparin Among Medical Inpatients With Chronic Obstructive Pulmonary Disease or Heart Failure

Background: Chronic obstructive pulmonary disease (COPD) and heart failure (HF) are risk factors for venous thromboembolism (VTE). Enoxaparin and unfractionated heparin (UFH) help prevent hospital-associated VTE, but few studies have compared them in COPD or HF. Objectives: To compare effectiveness, safety, and costs of enoxaparin vs UFH thromboprophylaxis in medical inpatients with COPD or HF. Methods: This retrospective cohort study included adults with COPD or HF from the Premier PINC AI Healthcare Database. Included patients received prophylactic-dose enoxaparin or UFH during a &gt;6-day index hospitalization (the first visit/admission that met selection criteria during the study period) between January 1, 2010, and September 30, 2016. Multivariable regression models assessed independent associations between exposures and outcomes. Hospital costs were adjusted to 2017 US dollars. Patients were followed 90 days postdischarge (readmission period). Results: In the COPD cohort, 114 174 (69%) patients received enoxaparin and 51 011 (31%) received UFH. Among patients with COPD, enoxaparin recipients had 21%, 37%, and 10% lower odds of VTE, major bleeding, and in-hospital mortality during index admission, and 17% and 50% lower odds of major bleeding and heparin-induced thrombocytopenia (HIT) during the readmission period, compared with UFH recipients (all P &lt;.006). In the HF cohort, 58 488 (58%) patients received enoxaparin and 42 726 (42%) received UFH. Enoxaparin recipients had 24% and 10% lower odds of major bleeding and in-hospital mortality during index admission, and 13%, 11%, and 51% lower odds of VTE, major bleeding, and HIT during readmission (all P &lt;.04) compared with UFH recipients. Enoxaparin recipients also had significantly lower total hospital costs during index admission (mean reduction per patient: COPD, $1280; HF, $2677) and readmission (COPD, $379; HF, $1024). Among inpatients with COPD or HF, thromboprophylaxis with enoxaparin vs UFH was associated with significantly lower odds of bleeding, mortality, and HIT, and with lower hospital costs. Conclusions: This study suggests that thromboprophylaxis with enoxaparin is associated with better outcomes and lower costs among medical inpatients with COPD or HF based on real-world evidence. Our findings underscore the importance of assessing clinical outcomes and side effects when evaluating cost-effectiveness.

Effectiveness, Safety, and Costs of Thromboprophylaxis with Enoxaparin or Unfractionated Heparin Among Medical Inpatients With Chronic Obstructive Pulmonary Disease or Heart Failure.

Background: Chronic obstructive pulmonary disease (COPD) and heart failure (HF) are risk factors for venous thromboembolism (VTE). Enoxaparin and unfractionated heparin (UFH) help prevent hospital-associated VTE, but few studies have compared them in COPD or HF. Objectives: To compare effectiveness, safety, and costs of enoxaparin vs UFH thromboprophylaxis in medical inpatients with COPD or HF. Methods: This retrospective cohort study included adults with COPD or HF from the Premier PINC AI Healthcare Database. Included patients received prophylactic-dose enoxaparin or UFH during a >6-day index hospitalization (the first visit/admission that met selection criteria during the study period) between January 1, 2010, and September 30, 2016. Multivariable regression models assessed independent associations between exposures and outcomes. Hospital costs were adjusted to 2017 US dollars. Patients were followed 90 days postdischarge (readmission period). Results: In the COPD cohort, 114 174 (69%) patients received enoxaparin and 51 011 (31%) received UFH. Among patients with COPD, enoxaparin recipients had 21%, 37%, and 10% lower odds of VTE, major bleeding, and in-hospital mortality during index admission, and 17% and 50% lower odds of major bleeding and heparin-induced thrombocytopenia (HIT) during the readmission period, compared with UFH recipients (all P <.006). In the HF cohort, 58 488 (58%) patients received enoxaparin and 42 726 (42%) received UFH. Enoxaparin recipients had 24% and 10% lower odds of major bleeding and in-hospital mortality during index admission, and 13%, 11%, and 51% lower odds of VTE, major bleeding, and HIT during readmission (all P <.04) compared with UFH recipients. Enoxaparin recipients also had significantly lower total hospital costs during index admission (mean reduction per patient: COPD, 2677) and readmission (COPD, 1024). Among inpatients with COPD or HF, thromboprophylaxis with enoxaparin vs UFH was associated with significantly lower odds of bleeding, mortality, and HIT, and with lower hospital costs. Conclusions: This study suggests that thromboprophylaxis with enoxaparin is associated with better outcomes and lower costs among medical inpatients with COPD or HF based on real-world evidence. Our findings underscore the importance of assessing clinical outcomes and side effects when evaluating cost-effectiveness.

Underestimation of Venous Thromboembolism Risk: A Common Health Care Quality Deficit

Venous thromboembolism (VTE) is a complication of hospitalization but not all patients are at high risk. VTE risk assessment models have been developed to identify patients whose risk is sufficient to warrant pharmacologic thromboprophylaxis. To ensure all patients are risk assessed upon admission, we implemented a mandatory risk assessment tool embedded in admission order sets in our electronic health record (EHR) system. We hypothesized that the accuracy of these risk assessments was variable. We performed a retrospective cohort study of patients discharged from the Johns Hopkins Hospital medicine service between January 1 st-December 31 st 2019. The cohort consisted of consecutive patients classified into normal, intermediate or low mobility groups using the Johns Hopkins Highest Level of Mobility score. Using a standardized chart review algorithm, elements of the Padua and Improve risk scores were determined using the admission note and the JH-HLM scores for mobility assessment. We report the results of the Padua score comparison. Provider risk assessments, VTE prophylaxis orders, symptomatic VTE, major bleeding (ISTH criteria) and deaths were determined by chart review. We measured concordance between provider risk factors identified and those identified on retrospective chart review. Statistical analyses were done using Chi-squared or Fisher's exact test and were performed using Stata v.18. The cohort consist of 2992 patients with a median age of 58 (Interquartile range (IQR) 45-70). Characteristics of the cohort are in Table 1. The median provider Padua score was 1 (IQR 0,3) compared with 2 (IQR 1,5) for chart review. Providers identified 2480 patients (82.9%) as being low risk compared with 1882 (62.9%) upon chart review (P&amp;lt;0.001). Differences in risk factor assessments are presented in Figure 1. Concordance rates between providers and chart review were high (93.6%-99.6%) for all risk factors except obesity (87.5%), heart failure (76.4%), reduced mobility (72.5%) and acute infection (66.1%).(Figure 1) Thirty-six VTE (27 DVT, 9 PE; 1.2%) occurred during the hospital stay and sixty-one (44 DVT;17 PE; 2.2%) within 3 months. Among patients who suffered an in-hospital VTE, providers assessed 29 (80.6%) as low risk compared with 13 (36.1%) by chart review. Fourteen patients (48.3%) were not prescribed prophylaxis. Forty-seven of 61 patients (77.0%) who developed VTE within 3 months were classified as low risk by providers compared with 26 (42.6%) among chart reviewers. Twenty-five (41.0%) were not prescribed prophylaxis. 727 of 2480 (29.3%) patients risk assessed as low risk by providers were assessed as being at high risk upon chart review. 707 of 2480 (28.5%) low risk patients were not prescribed prophylaxis. 157 of these 707 (22.2%) would have been prescribed prophylaxis based upon chart review. Among these 157 patients, 7 VTE occurred during the hospital stay and 11 events occurred within 3 months. Major bleeding occurred during prophylaxis in 4 patients (0.17%). Underestimation of VTE risk is common in hospitalized medically-ill patients. Development of improved EHR VTE risk assessment tools that assist the provider in identifying patient risk factors could improve VTE prevention and reduce hospital-associated VTE.

Contemporary adequacy of thromboprophylaxis in acutely ill medical patients in Switzerland: a bi-centric prospective cohort.

Venous thromboembolism is a dreaded complication of hospitalised patients, with associated morbidity, mortality and increased healthcare costs. Previous studies have shown that pharmacological thromboprophylaxis, though effective, is inadequately administered in a large proportion of medical inpatients. Our primary aim was to evaluate the contemporary adequacy of thromboprophylaxis in medical inpatients admitted to two Swiss hospitals (a university hospital and a regional hospital). The secondary aim was to estimate the 90-day incidence of relevant thrombotic and bleeding events. In this prospective cohort, patients were recruited at the University Hospital of Geneva and the Regional Hospital of Lugano between September 2020 and February 2021 and followed for 90 days for venous thromboembolism and bleeding events. The adequacy of thromboprophylaxis (pharmacological and/or mechanical) at 24h after hospital admission was evaluated according to the simplified Geneva risk score for hospital-associated venous thromboembolism. Among 200 participants (100 at each site, mean age of 65 years), 57.5% were deemed at high risk of venous thromboembolism at admission. Thromboprophylaxis was adequate in 59.5% (95% CI 52.3-66.4%). Among high-risk and low-risk inpatients, thromboprophylaxis was adequate in 71.3% and 43.5%, respectively, with differences between sites. At 90 days, risks of adjudicated venous thromboembolism, major bleeding and mortality were 1.5%, 1.5% and 6.0%, respectively. Despite the extensive literature on thromboprophylaxis, the adequacy of thromboprophylaxis has not improved and remains insufficient among medical inpatients. Implementation and evaluation of clinical decision support systems are critically needed in this field. gov number: NCT05306821.

Effectiveness of an artificial intelligence clinical assistant decision support system to improve the incidence of hospital-associated venous thromboembolism: a prospective, randomised controlled study

BackgroundThromboprophylaxis has been determined to be safe, effective and cost-effective for hospitalised patients at venous thromboembolism (VTE) risk. However, Chinese medical institutions have not yet fully used or improperly used...

Prevention of Hospital-Associated Venous Thromboembolism: A Road Map to Defect-Free Care.

Prevention of Hospital-Associated Venous Thromboembolism: A Road Map to Defect-Free Care.

Reliability of Risk Assessment for Intra-Hospital Venous Thromboembolism: An Exploratory Cross-Sectional Study.

Hospital-associated venous thromboembolism (VTE) is a major cause of unintended death in hospitalized patients. Standardized and reasonable prevention measures may reduce its occurrence effectively. This study aims to analyze the consistency of VTE risk assessment by physicians and nurses and its potential causes. A total of 897 patients admitted to Shanghai East Hospital from December 2021 to March 2022 were recruited. The VTE assessment scores of physicians and nurses and the activities of daily living (ADL) scores within the first 24 h of admission were collected for each patient. Cohen's Kappa values were calculated to assess the inter-rater consistency of these scores. VTE scores were fairly consistent between doctors and nurses in both surgical (Kappa = 0.30, 95% CI: 0.25-0.34) and non-surgical (Kappa = 0.35, 95% CI: 0.31-0.38) departments. There was moderate agreement in VTE risk assessment between doctors and nurses in surgical departments (Kappa = 0.50, 95% CI: 0.38-0.62) while fair agreement in VTE risk assessment between doctors and nurses in non-surgical departments (Kappa = 0.32, 95% CI: 0.26-0.40). The assessment of the mobility impairment component was fairly consistent between doctors and nurses in the non-surgical departments (Kappa = 0.31, 95% CI: 0.25-0.37). Due to the poor consistency of VTE risk assessment between doctors and nurses, it is necessary to provide systematic training and develop a standardized assessment process for healthcare professionals to construct a scientific and effective VTE prevention and treatment system.

Predicting post-discharge venous thromboembolism and bleeding among medical patients: External validation of a novel risk score utilizing ubiquitous biomarkers

BackgroundPost-hospitalization thromboprophylaxis can reduce venous thromboembolism (VTE) risk for non-surgical patients but may carry bleeding risks. We aimed to externally validate the Intermountain Risk Scores for hospital-associated venous thromboembolism (HA-VTE IMRS) and major bleeding (HA-MB IMRS) for VTE and bleeding outcomes. MethodsRetrospective cohort study of adult patients discharged alive from medical services between 2015 and 2019. HA-VTE IMRS and HA-MB IMRS were calculated at the time of hospital discharge and dichotomized as high- or low-risk as described in the derivation manuscript. 90-day post-discharge VTE outcomes were assessed from diagnostic radiology reports, and bleeding outcomes were assessed using ICD-10 codes and blood bank transfusion records. ResultsAmong 113,578 patients in the study, 66,340 patients (58.4 %) had a low-risk HA-VTE IMRS <7, versus 47,238 (41.6 %) high-risk ≥7. For bleed prediction, 71,576 patients (63 %) had a low-risk HA-MB IMRS <8, versus 42,002 (37 %) high-risk ≥8. VTE incidence was 1.1 % and 0.6 % while major bleeding incidence was 1.3 % and 0.1 % in high-risk versus low-risk cohorts, respectively. AUCs for VTE and bleed outcome discrimination were 0.59 and 0.78, respectively. Patients with a combined high-risk VTE score and low-risk bleeding score comprised 14.5 % of the population. ConclusionIn this external validation study, the HA-VTE IMRS had poor discrimination for VTE but the HA-MB IMRS had good discriminatory ability for major bleeding events. A sizable minority of patients were categorized as high VTE risk with low bleed risk, a population which may have an optimal risk-benefit profile for post-hospital thromboprophylaxis.

Examining the benefit of graduated compression stockings in the prevention of hospital-associated venous thromboembolism in low-risk surgical patients: a multicentre cluster randomised controlled trial (PETS trial)

IntroductionHospital-acquired thrombosis (HAT) is defined as any venous thromboembolism (VTE)-related event during a hospital admission or occurring up to 90 days post discharge, and is associated with significant morbidity, mortality...

Assessment of nurses' knowledge of the prevention of hospital-associated venous thromboembolism in a tertiary health institution in Nigeria

Assessment of nurses' knowledge of the prevention of hospital-associated venous thromboembolism in a tertiary health institution in Nigeria

Prevention of hospital-associated venous thromboembolism - Insight from the Getting It Right First Time thrombosis survey in England.

A national Venous Thromboembolism (VTE) Prevention Programme was introduced in England in 2010, with limited subsequent study of its impact. Whilst the National Outcomes Framework reports VTE deaths related to hospitalisation annually, there are little data regarding VTE prevention practice or non-fatal VTE associated with hospitalisation. We report the first national thrombosis survey undertaken in collaboration with Getting It Right First Time. 98 Trusts (103 sites, 67% of 144 invited) participated in at least one survey, contributing data regarding VTE prevention in 9553 patients. Anti-coagulant thromboprophylaxis was prescribed to 88% (when indicated), with 8.1% of patients missing doses. Written patient information was provided to 31%. Of 4595 episodes of hospital-associated VTE, 13% were considered potentially preventable. The survey highlights the success of the national programme and areas for improvement in delivery of thromboprophylaxis and patient information.

Trends and Risk Factors for Venous Thromboembolism Among Hospitalized Medical Patients

While hospital-associated venous thromboembolism (HA-VTE) is a known complication of hospitalization, contemporary incidence and outcomes data are scarce and methodologically contested. To define and validate an automated electronic health record (EHR)-based algorithm for retrospective detection of HA-VTE and examine contemporary HA-VTE incidence, previously reported risk factors, and outcomes. This cohort study was conducted using hospital admissions between January 1, 2013, and June 30, 2021, with follow-up until December 31, 2021. All medical (non-intensive care unit) admissions at an integrated health care delivery system with 21 hospitals in Northern California during the study period were included. Data were analyzed from January to June 2022. Previously reported risk factors associated with HA-VTE and administration of pharmacological prophylaxis were evaluated as factors associated with HA-VTE. Yearly incidence rates and timing of HA-VTE events overall and by subtype (deep vein thrombosis, pulmonary embolism, both, or unknown), as well as readmissions and mortality rates. Among 1 112 014 hospitalizations involving 529 492 patients (268 797 [50.8%] women; 75 238 Asian [14.2%], 52 697 Black [10.0%], 79 398 Hispanic [15.0%], and 307 439 non-Hispanic White [58.1%]; median [IQR] age, 67.0 [54.0-79.0] years), there were 13 843 HA-VTE events (1.2% of admissions) occurring in 10 410 patients (2.0%). HA-VTE events increased from 307 of 29 095 hospitalizations (1.1%) in the first quarter of 2013 to 551 of 33 729 hospitalizations (1.6%) in the first quarter of 2021. Among all HA-VTE events, 10 746 events (77.6%) were first noted after discharge. In multivariable analyses, several factors were associated with increased odds of HA-VTE, including active cancer (adjusted odds ratio [aOR], 1.96; 95% CI, 1.85-2.08), prior VTE (aOR, 1.71; 95% CI, 1.63-1.79), and reduced mobility (aOR, 1.63; 95% CI, 1.50-1.77). Factors associated with decreased likelihood of HA-VTE included Asian race (vs non-Hispanic White: aOR, 0.65; 95% CI, 0.61-0.69), current admission for suspected stroke (aOR, 0.73; 95% CI, 0.65-0.81), and Hispanic ethnicity (vs non-Hispanic White: aOR, 0.81; 95% CI, 0.77-0.86). HA-VTE events were associated with increased risk of readmission (hazard ratio [HR], 3.33; 95% CI, 3.25-3.41) and mortality (HR, 1.63; 95% CI, 1.57-1.70). This study found that HA-VTE events occurred in 1.2% of medical admissions, increased over time, and were associated with increased adverse outcomes. These findings suggest that approaches designed to mitigate occurrence and outcomes associated with HA-VTE may remain needed.

Consolidate the foundation, steadily promote and comprehensively improve the quality control in prevention and management of venous thromboembolism in China

Hospital-associated venous thromboembolism (HA-VTE) has become a public health problem that seriously affects the quality of medical care and patient safety. Many countries regarded VTE prevention as a key element of medical quality management, carried out quality improvement work in VTE prevention and achieved remarkable results. In China, there is also unremitting efforts and explorations in the field of VTE prevention and management. The national program for prevention and management of pulmonary embolism and deep vein thrombosis was officially launched. Through a series of measures such as excellent center construction, regional alliance, and strengthening of quality control and informatization, the national program has greatly promoted the construction of VTE prevention and management system in hospitals across the country. Strengthening the prevention and treatment of VTE has become the common will of the government, hospital administrators, clinical medical staff and the public. In the future, we need to continue to steadily promote the prevention and management of VTE, and comprehensively improve the quality control management level of VTE prevention and management in hospitals.

Use of a real-time risk-prediction model to identify pediatric patients at risk for thromboembolic events: study protocol for the Children’s Likelihood Of Thrombosis (CLOT) trial

BackgroundPediatric patients have increasing rates of hospital-associated venous thromboembolism (HA-VTE), and while several risk-prediction models have been developed, few are designed to assess all general pediatric patients, and none has been shown to improve patient outcomes when implemented in routine clinical care.MethodsThe Children’s Likelihood Of Thrombosis (CLOT) trial is an ongoing pragmatic randomized trial being conducted starting November 2, 2020, in the inpatient units at Monroe Carell Jr. Children’s Hospital at Vanderbilt in Nashville, TN, USA. All admitted patients who are 21 years of age and younger are automatically enrolled in the trial and randomly assigned to receive either the current standard-of-care anticoagulation practice or the study intervention. Patients randomized to the intervention arm are assigned an HA-VTE risk probability that is calculated from a validated VTE risk-prediction model; the model is updated daily with the most recent clinical information. Patients in the intervention arm with elevated risk (predicted probability of HA-VTE ≥ 0.025) have an additional review of their clinical course by a team of dedicated hematologists, who make recommendations including pharmacologic prophylaxis with anticoagulation, if appropriate. The anticipated enrollment is approximately 15,000 patients. The primary outcome is the occurrence of HA-VTE. Secondary outcomes include initiation of anticoagulation, reasons for not initiating anticoagulation among patients for whom it was recommended, and adverse bleeding events. Subgroup analyses will be conducted among patients with elevated HA-VTE risk.DiscussionThis ongoing pragmatic randomized trial will provide a prospective assessment of a pediatric risk-prediction tool used to identify hospitalized patients at elevated risk of developing HA-VTE. Trial registrationClinicalTrials.gov NCT04574895. Registered on September 28, 2020. Date of first patient enrollment: November 2, 2020.

Thromboprophylaxis for venous thromboembolism prevention in hospitalized patients with cirrhosis: Guidance from the SSC of the ISTH

Hospital‐associated venous thromboembolism (HA‐VTE) is a major cause of morbidity and mortality and is internationally recognized as a significant patient safety issue. While cirrhosis was traditionally considered to predispose to bleeding, these patients are also at an increased risk of VTE, with an associated increase in mortality. Hospitalization rates of patients with cirrhosis are increasing, and decisions regarding thromboprophylaxis are complex due to the uncertain balance between thrombosis and bleeding risk. This is further accentuated by derangements of hemostasis in patients with cirrhosis that are often considered contraindications to pharmacological thromboprophylaxis. Due to the strict inclusion and exclusion criteria of seminal studies of VTE risk assessment and thromboprophylaxis, there is limited data to guide decision making in this patient group. This guidance document reviews the incidence and risk factors for HA‐VTE in patients with cirrhosis, outlines evidence to inform the use of thromboprophylaxis, and provides pragmatic recommendations on VTE prevention for hospitalized patients with cirrhosis. In brief, in hospitalized patients with cirrhosis:1.We suggest inclusion of portal vein thrombosis as a distinct clinically important endpoint for future studies.2.We recommend against the use of thrombocytopenia and/or prolongation of prothrombin time/international normalized ratio as absolute contraindications to anticoagulant thromboprophylaxis.3.We suggest anticoagulant thromboprophylaxis in line with local protocols and suggest low molecular weight heparin (LMWH) or fondaparinux over unfractionated heparin (UFH). In renal impairment, we suggest LMWH over UFH. For critically ill patients, we suggest case‐by‐case consideration of thromboprophylaxis.4.We recommend research to refine VTE risk stratification, and to establish the optimal dosing and duration of thromboprophylaxis.

Prevention of Hospital Associated Venous Thromboembolism in Psychiatric Inpatients- a Survey of Current Practice Within Mental Health Trusts in England

AimsGeneral hospital inpatients are routinely risk assessed for hospital associated venous thromboembolism (HAT) and given appropriate thromboprophylaxis if indicated. However, mental health trusts have not taken a similar approach in psychiatric inpatients, despite known risk factors, including some unique to psychiatric inpatients. We explored current practice of HAT prevention in English psychiatric inpatients.MethodsA Freedom of Information Act (FOI) request was sent to all 71 English mental health trusts, asking whether there was a Venous Thromboembolism (VTE) policy, whether a VTE risk assessment tool was being used, what is looked like, and the incidence of HAT in their psychiatric inpatients i.e., VTE during admission or occurring up to 90 days post discharge.ResultsWe received 54 unique responses (76%) to the FOI. Of these, 36 (86%) shared their VTE policy, 26 (72%) of which had been adapted for this population; 38 (90%) shared their VTE risk assessment tool, of which 17 (45%) were adapted from the Department of Health VTE risk assessment tool.Only five trusts out of 42 (12%) monitored VTE events up to 90 days post-discharge and 4 of these shared their monitoring policy. Only 18 (43%) were able to provide data on the number of psychiatric patients diagnosed with a VTE during their stay and up to 90 days post discharge between February 2016–2021, 6 (14%) said they would incur costs to collect this data and 9 (21%) were unable to access this data. Where information was provided, the number of HAT events ranged from 0–224 within each trust. Of the 18 trusts who provided data, a total of 514 events were recorded between Feb 2016-Feb 2021, but none of the trusts were able to confirm if this included VTE events up to 90 days post discharge.ConclusionOur FOI survey suggest a high incidence of VTE in psychiatric patients and indicate wide variation in HAT prevention in English hospitalised psychiatric patients. Most had a VTE Trusts had a policy in place, with 45% having a VTE risk assessment tool that listed risk factors unique to psychiatric patients, adapting VTE risk assessment tools in this way may lead to a greater use of thromboprophylaxis. The lack of access to data on HAT by mental health trusts is concerning. Further research is required to understand the rates of VTE, validate a VTE risk assessment tool and conduct trials looking at the benefit of thromboprophylaxis in psychiatric inpatients.

Post‐discharge thrombosis and bleeding in medical patients: A novel risk score derived from ubiquitous biomarkers

BackgroundSome hospitalized medical patients experience venous thromboembolism (VTE) following discharge. Prophylaxis extended beyond hospital discharge (extended duration thromboprophylaxis [EDT]) may reduce this risk. However, EDT is costly and can cause bleeding, so selecting appropriate patients is essential. We formerly reported the performance of a mortality risk prediction score (Intermountain Risk Score [IMRS]) that was minimally predictive of 90‐day hospital‐associated venous thromboembolism (HA‐VTE) and major bleeding (HA‐MB). We used the components of the IMRS to calculate de novo risk scores to predict 90‐day HA‐VTE (HA‐VTE IMRS) and major bleeding (HA‐MB IMRS). MethodsFrom 45 669 medical patients we randomly assigned 30 445 to derive the HA‐VTE IMRS and the HA‐MB IMRS. Backward stepwise regression and bootstrapping identified predictor covariates from the blood count and basic chemistry. These candidate variables were split into quintiles, and the referent quintile was that with the lowest event rate for HA‐VTE and HA‐MB; respectively. A clinically relevant rate of HA‐VTE and HA‐MB was used to inform outcome rates. Performance was assessed in the derivation set of 15 224 patients. ResultsThe HA‐VTE IMRS and HA‐MB IMRS area under the receiver operating curve (AUC) in the derivation set were 0.646, and 0.691, respectively. In the validation set, the HA‐VTE IMRS and HA‐MB IMRS AUCs were 0.60 and 0.643. ConclusionsRisk scores derived from components of routine labs ubiquitous in clinical care identify patients that are at risk for 90‐day postdischarge HA‐VTE and major bleeding. This may identify a subset of patients with high HA‐VTE risk and low HA‐MB risk who may benefit from EDT.