Prescription Of Thromboprophylaxis Research Articles

Evaluation of a Risk Screening Checklist for Venous Thromboembolism Prophylaxis in a Women and Newborn Hospital

ABSTRACT Introduction The venous thromboembolism (VTE) risk screening forms were developed to allow for recording identified risk factors for VTE including thrombophilia, history of VTE, postpartum hemorrhage, and cesarean delivery, and documentation of specific actions taken to mitigate these risks and reduce complications due to VTE. Methods Compliance with hospital guidelines in assessing VTE risk and appropriate prescribing of thromboprophylaxis was evaluated prior to the introduction of VTE risk screening forms (March 2022). Efficacy of the new VTE risk screening forms was also assessed (April 2023). Patient discharge summaries and patient medical records including medication charts were used to review the documentation of VTE risk assessments and details of thromboprophylaxis prescribing. Results Of 74 postnatal patients, 37.8% had VTE risk assessment documented prior to the introduction of VTE risk screening forms. Of 37 patients identified to be at moderate to high risk of VTE requiring pharmacological prophylaxis, 70.3% (n = 26) were appropriately prescribed pharmacological prophylaxis. After the risk screening forms were introduced, a total of 67 antenatal, postnatal, and gynecologic patients were studied. Of these, 32.8% (n = 22) of patients had all required fields completed appropriately. When using the forms, 26.9% (n = 7) of postnatal and 88% (n = 22) of gynecological patients were rated as medium or high risk, and all received medical review within 24 hours. Pharmacological prophylaxis was indicated in 88% (n = 22) of gynecological, 43.8% (n = 7) of antenatal, and 38.5% (n = 10) of postnatal patients, and all were appropriately prescribed. Conclusion The guideline review and introduction of VTE risk screening forms was valuable to provide guidance in the risk assessment for VTE and to identify patients requiring prophylaxis.

Effectiveness of an educational strategy in increasing the prescription of adequate thromboprophylaxis in the internal medicine service of general hospital

Objetivo: Determinar el impacto de una intervención educativa sobre la frecuencia de prescripciones médicas adecuadas de tromboprofilaxis en un servicio de medicina de un hospital general. Material y métodos: Estudio quasi experimental, en el cual en la fase pre-intervención se obtuvieron las frecuencias de indicación de tromboprofilaxis adecuada por parte de los médicos del servicio de medicina. Se realizó una intervención educativa de 8 semanas a este mismo grupo de médicos. En la fase post intervención se midió la frecuencia de la tromboprofilaxis adecuada a los 2 y 4 meses después de la intervención. Resultados: La intervención educativa se implementó en 112 médicos residentes de las especialidades de medicina. La totalidad de prescripciones fueron hechas por los médicos residentes de primer año y refrendadas por su médico supervisor. Previamente a la intervención se obtuvieron 47 (44,35%) prescripciones adecuadas, 13 (12,26%) subóptimas, 4 (3,77%) inadecuadas y 42 (39, 62%) ausencia de prescripción. Luego de la intervención se obtuvieron a los 2 meses subsiguientes: 78 (75,72%) prescripciones adecuadas, 7 (6,79%) subóptimas, 4 (2,91%) inadecuadas y 15 (14,58%) ausencias de prescripción, habiendo diferencia significativa con el nivel basal. A los 4 meses subsiguientes postintervención se obtuvieron: 86 (83,49%) adecuada, 5(4,85%) subóptima, 2 (1,94%) inadecuada y 10 (9,72%) ausencia de prescripción, habiendo diferencia significativa con el nivel basal. No hubo aumento en la frecuencia de sobre uso. Conclusiones: La aplicación de una estrategia educativa al personal médico fue efectiva en el incremento de las prescripciones de tromboprofilaxis correctamente indicadas en un servicio de medicina. No se encontró sobreuso de la tromboprofilaxis luego de la intervención.

Clinical decision support to enhance venous thromboembolism pharmacoprophylaxis prescribing for pediatric inpatients with COVID-19.

To design and evaluate a clinical decision support (CDS) module to improve guideline concordant venous thromboembolism (VTE) pharmacoprophylaxis prescribing for pediatric inpatients with COVID-19. The proportion of patients who met our institutional clinical practice guideline's (CPG) criteria for VTE prophylaxis was compared to those who triggered a CDS alert, indicating the patient needed VTE prophylaxis, and to those who were prescribed prophylaxis pre and post the launch of a new VTE CDS module to support VTE pharmacoprophylaxis prescribing. The sensitivity, specificity, positive predictive value (PPV), negative predictive value, F1-score and accuracy of the tool were calculated for the pre- and post-intervention periods using the CPG recommendation as the gold standard. Accuracy was defined as the sum of the true positives and true negatives over the sum of the true positives, false positives, true negatives, and false negatives. Logistic regression was used to identify variables associated with correct thromboprophylaxis prescribing. A significant increase in the proportion of patients triggering a CDS alert occurred in the post-intervention period (44.3% vs. 6.9%, p<.001); however, no reciprocal increase in VTE prophylaxis prescribing was achieved (36.6% vs. 40.9%, p=.53). The updated CDS module had an improved sensitivity (55.0% vs. 13.3%), NPV (44.9% vs. 36.3%), F1-score (66.7% vs. 23.5%), and accuracy (62.5% vs. 42.0%), but an inferior specificity (78.6% vs. 100%) and PPV (84.6% vs. 100%). The updated CDS model had an improved accuracy and overall performance in correctly identifying patients requiring VTE prophylaxis. Despite an increase in correct patient identification by the CDS module, the proportion of patients receiving appropriate pharmacologic prophylaxis did not change. CDS tools to support correct VTE prophylaxis prescribing need ongoing refinement and validation to maximize clinical utility.

Thromboprophylaxis strategies in patients undergoing endovenous thermal ablation: a UK survey

Introduction: It remains unclear whether patients undergoing endovenous thermal ablation (EVTA) for superficial venous incompetence (SVI) should receive pharmacological thromboprophylaxis. A survey was conducted to assess current thromboprophylaxis practices across the UK in patients undergoing EVTA for SVI. Methods: To examine the thromboprophylaxis practices of clinicians performing EVTA for SVI in the UK, an online survey was developed using the Qualtrics online survey tool. The survey link was circulated via email to members of the multidisciplinary collaborative Vascular and Endovascular Research Network (VERN) and promoted through social media. The primary focus of the survey was to gather information regarding venous thromboembolism (VTE) prophylaxis during EVTA for SVI. Results: A total of 32 vascular surgeons and one vascular nurse specialist based in the UK participated in the survey. All respondents reported routine prescription of compression therapy in the immediate postoperative period. Of all the respondents, 67% (n=22) reported routine prescription of pharmacological thromboprophylaxis during the peri-procedural period. Extended prophylaxis was routinely offered by 15% (n=5) of all respondents. Among those who provided extended prophylaxis, the majority (80%, n=4) used low molecular weight heparin (LMWH), while 20% (n=1) opted for a direct-acting oral anticoagulant (DOAC). Conclusion: The findings from this survey indicate that a significant proportion of patients undergoing EVTA for SVI routinely receive pharmacological thromboprophylaxis, with a single perioperative dose of LMWH being the prevailing practice. However, there is a notable lack of robust high-quality evidence to substantiate this practice. Grade A evidence is required to assess the potential benefit of pharmacological thromboprophylaxis in the context of EVTA to guide the development of clinically relevant guidelines. Should pharmacological thromboprophylaxis prove to offer no additional benefit for this specific patient population, this could result in cost savings for the NHS and enable patients to avoid unwanted side effects associated with anticoagulation therapy.

Optimization of Thromboprophylaxis Use in Hospitalized Pediatric Patients Through Implementation of a Venous Thromboembolism Risk Assessment Tool.

Venous thromboembolism (VTE) is a leading cause of hospital-acquired morbidity for pediatric patients. Pharmacological thromboprophylaxis increases the risk of adverse events such as bleeding complications. There exists a need for a universal VTE risk assessment tool to aid in thromboprophylaxis prescribing while minimizing the risk of adverse events. The objective of this study is to investigate if implementation of a VTE risk assessment tool is associated with a change in the rate of thromboprophylaxis prescribing. This retrospective study evaluated the change in thromboprophylaxis prescribing pre and post implementation of a VTE risk assessment tool. Patients were excluded if they were pregnant, diagnosed with VTE ≤48 hours of admission, presented with VTE symptoms, or if they were diagnosed with multisystem inflammatory syndrome in children (MIS-C) or coronavirus disease (COVID-19). A total of 186 pediatric patients were included in this study. Thromboprophylaxis was prescribed in 16/93 (17.12%) and 75/93 (80.6%) patients in the pre- and post-implementation group, respectively (95% CI, 0.523-0.745; p < 0.001). No VTE events occurred in either group. Bleeding complications occurred in 3.2% and 7.5% of patients in the pre- and post-implementation groups, respectively. The risk tool was used in 80.6% of patients; providers used the tool correctly in 48% of patients and incorrectly in 52% of patients. Implementation of a VTE risk assessment tool was associated with a statistically significant change in the rate of thromboprophylaxis prescribing. Incorrect use may be minimized by providing provider reeducation and making modifications to the order set.

Thromboprophylaxis in Patients Admitted to the Surgical Ward: Clinical Audit.

Hospital-acquired thrombosis (HAT) is associated with significant morbidity, mortality, and financial burden globally. Following trusted guidelines for VTE prevention has shown effective, safe, and satisfactory results. This prompts national collaborative efforts to maintain a consensus approach for the safe risk assessment of inpatients and the prescription of thromboprophylaxis. This study aimed to detect and estimate deviations from international thromboprophylaxis protocols. The study also aimed to raise the quality of practice and adherence to evidence-based protocols in Alshuhada Teaching Hospital. A cross-sectional audit of general surgical inpatients was performed from October 2021 to May 2022. The first cycle was from 1/10/2021 to 21/10/2021, and the second cycle was from 13/5/2022 to 31/5/2022. The target population was adults aged >18 years. Data were collected via an online checklist on two separate occasions. The criteria were based on the NICE guideline for venous thromboembolism in individuals aged over 16 years: "Reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism NG89". Forty-five surgical inpatients were included in this study: 20 in the first cycle and 25 in the second cycle. The first-cycle report showed that only 25% of VTE candidates received this regimen. In the second cycle, practice significantly improved, with 92% of admitted patients having their risk assessment tool completed within 24 h of admission. 79% of VTE prophylaxis candidates were prescribed adequate pharmacological prophylaxis within 14 h of admission. The rate of adequate thromboprophylaxis for inpatients undergoing surgery was very low before clinicians received education on VTE prevention, whereas was evidently high after they had received them. The cause of non-adherence in the pre-intervention phase was a lack of adequate knowledge regarding the magnitude and burden of HAT and the importance of thromboprophylaxis, which has a potential role in preventing the majority of HAT.

Evaluation of the Quality and Safety of Venous Thromboembolism Prophylaxis Among Gastroenterology Inpatients at a Tertiary Hospital in Australia.

Background and objective: Hospital acquired venous thromboembolisms (VTEs) are common and preventable. The Queensland Health VTE prophylaxis guidelines, developed in 2018, provide guidance for risk assessment, and prescribing of anticoagulation for prophylaxis and treatment of hospital inpatients. Currently, there are limited recommendations for gastroenterology patients. This study investigated the completion of VTE risk assessments, and the appropriateness of VTE prophylaxis regimens, in accordance with Queensland Health guidelines for gastroenterology patients. The quality and safety of VTE prophylaxis regimens was assessed based on their VTE risk and bleeding risk. Method: A retrospective study was conducted by obtaining a random sample of gastroenterology patients admitted to a tertiary Australian hospital, from 1st May 2019 and 1st May 2020, to determine the compliance of VTE risk assessment and thromboprophylaxis prescribing with state-wide VTE guidelines. The quality and safety of thromboprophylaxis was evaluated using the modified Caprini and HASBLED scores, and subsequent thromboprophylaxis-related complications. Results: Of the 94 patients reviewed, 68 did not have contraindications to thromboprophylaxis. Of these 68 patients, 32 (47%) had no VTE risk assessment recorded in their clinical records and were not prescribed any thromboprophylaxis during the hospitalization. There was no significant difference between thromboprophylaxis prescribing for patients with low VTE risk, compared to moderate to high VTE risk (P = .075). There was a trend for decrease in thromboprophylaxis prescribing as HASBLED bleeding risk score increased, and patients with moderate-high bleed risk were less likely to be prescribed thromboprophylaxis (P = .006). There were no thromboprophylaxis related complications identified. Conclusion: It is essential that all patients have a clearly documented risk assessment and are prescribed thromboprophylaxis according to best practice guidelines. The prescription of venous thromboembolism prophylaxis should continue to be individualized, with each patient assessed holistically.

Formal and informal venous thromboembolism risk assessment and impact on prescribing of thromboprophylaxis: a retrospective cohort study

BackgroundHospital-acquired thrombosis (HAT) is a leading cause of preventable death and disability worldwide. HAT includes any venous thromboembolic (VTE) event occurring in-hospital or within 90-days of hospitalisation. Despite availability of evidence-based guidelines for HAT risk assessment and prophylaxis, guidelines are still underutilised.AimTo determine the proportion of patients who developed HAT that could have been potentially prevented with appropriate VTE risk assessment and prophylaxis at a large public hospital in New Zealand. Additionally, the predictors of VTE risk assessment and thromboprophylaxis were examined.MethodVTE patients admitted under general medicine, reablement, general surgery, or orthopaedic surgery service were identified using ICD-10-AM codes. Data were collected on patient characteristics, VTE risk factors, and the thromboprophylaxis regimen prescribed. The hospital VTE guidelines were used to determine rates of VTE risk assessment and the appropriateness of thromboprophylaxis.ResultsOf 1302 VTE patients, 213 HATs were identified. Of these, 116 (54%) received VTE risk assessment, and 98 (46%) received thromboprophylaxis. Patients who received VTE risk assessment were 15 times more likely to receive thromboprophylaxis (odds ratio [OR] = 15.4; 95% CI 7.65–30.98) and 2.8 times more likely to receive appropriate thromboprophylaxis (OR = 2.79; 95% CI 1.59–4.89).ConclusionA large proportion of high-risk patients who were admitted to medical, general surgery and reablement services and who developed HAT did not receive VTE risk assessment and thromboprophylaxis during their index admission, demonstrating a significant gap between guideline recommendations and clinical practice. Implementing mandatory VTE risk assessment and adherence to guidelines to improve thromboprophylaxis prescription in hospitalised patients may help reduce the burden of HAT.

Incidence of Venous Thromboembolism After Hip Arthroscopy Is Low With or Without Prophylaxis but Risk Factors Include Oral Contraceptive Use, Obesity, and Malignancy

To determine the incidence of and risk factors for symptomatic venous thromboembolism (VTE) after hip arthroscopy (HA) and thromboprophylaxis prescription utilization for this procedure. The PearlDiver Mariner database was queried using Current Procedural Terminology codes to identify adult patients (aged ≥ 18 years) who underwent HA between 2010 and 2020. Patient demographic information, including age, oral contraceptive use, and medical comorbidities, as well as perioperative thromboprophylaxis utilization, was recorded using International Classification of Diseases codes and National Drug Codes. The incidence of postoperative VTE within 90 days was determined. Multivariate logistic regression was used to identify predictors of perioperative thromboprophylaxis utilization and risk factors for VTE. The queried records identified 60,181 patients who met the inclusion criteria. Of these patients, 367 (0.6%) experienced VTE, including deep venous thrombosis (0.5%) and/or pulmonary embolism (0.2%). Approximately 2.1% of patients used thromboprophylaxis, including aspirin (1.1%), low-molecular-weight heparin (0.9%), and oral factor Xa inhibitors (0.1%). Oral contraceptive pill use (adjusted odds ratio [aOR], 2.16; 95% confidence interval [CI], 1.34-3.46), obesity (aOR, 1.37; 95% CI, 1.05-1.79), and a history of malignancy (aOR, 1.69; 95% CI, 1.12-2.54) were associated with increased odds of experiencing VTE. Perioperative thromboprophylaxis (aOR, 0.52; 95% CI, 0.19-1.39) was not significantly associated with decreased odds of experiencing VTE. However, obesity (aOR, 1.17; 95% CI, 1.00-1.38) and hypertension (aOR, 1.17; 95% CI, 1.02-1.36) were associated with increased odds of thromboprophylaxis prescription utilization. Although the overall risk of symptomatic VTE after HA remains low, oral contraceptive use, obesity, and a history of malignancy are associated with increased odds of thromboembolic events within 90 days. Routine thromboprophylaxis after HA may not be indicated in all patients but can be considered based on patient-specific risk factors. Level III, retrospective prognostic comparative trial.

Risk assessment and compliance with hospital guidelines for venous thromboprophylaxis after gynecological surgeries

Background and objective: Venous thromboembolism after gynecological surgery is a major cause of morbidity and mortality. This study aimed to determine the venous thromboembolism risk profile of women who underwent gynecological surgery at a tertiary hospital and review the prescribed venous thromboembolism prophylaxis. Methods: An audit review study was conducted on 490 women who underwent major and minor gynecological surgeries at the Maternity Teaching Hospital, Erbil city, Kurdistan Region, Iraq, from 1st December 2019 to 31st December 2020, regarding their risk of developing postoperative venous thromboembolism using the 2013 modified Caprini venous thromboembolism risk assessment model to determine their risk and the correct thromboprophylaxis prescription. Results: According to appropriate thromboprophylaxis administration of low molecular weight heparin, it was administered to two-thirds of the women. It was sufficient in 33.1% of the women, and only 8.2% of the women received it for the correct duration. The probability of incorrect decision was higher for the major surgeries than for minor surgeries [odds ratio (OR) = 15.5; 95% confidence interval (95% CI) =3.01–80.1]. Moderate risk carried a much higher probability of an incorrect decision than low risk (OR = 196.8; 95%CI = 30.4–1270.5), whereas the association with high risk was not significant. When low molecular weight heparin was administered, there was a higher probability of a wrong decision than when low molecular weight heparin was not administered (OR = 26.4; 95%CI = 7.1–97.6). Conclusion: The gynecologists' adherence to venous thromboembolism prophylaxis after major and minor gynecological surgeries at the hospital mandates more training for all healthcare providers. Keywords: Audit; Thromboprophylaxis; Caprini RAM 2013; Adherence to guidelines; Gynecological surgery.

Thromboembolic events in COVID-19 ambulatory patients: An observational study about incidence, and thromboprophylaxis outcomes.

IntroductionThere are no clear data about the incidence and the prophylactic strategies of arterial and venous thromboembolic events (TE) in COVID-19 ambulatory patients. Thus, we conducted this study to analyze thromboembolic complications in this setting and to assess thromboprophylaxis management and outcomes in the real life.Patients and methodsThis is an observational study including Covid-19 ambulatory patients. We assessed incidence of venous and arterial TE events as well as thromboprophylaxis outcomes and hemorrhagic complications. We defined high risk thrombo-embolic factor according to the Belgian guidelines which are the only guidelines that described thromboprophylaxis in COVID-19 ambulatory patients.ResultsWe included 2089 patients with a mean age of 43±16 years. The incidence of 30 days venous and arterial TE complications in our cohort was 1%. Venous thromboembolic complications occurred in 0.8% and arterial thromboembolic complications occurred in 0.3%.We noted at least one high-risk TE factor in 18.5% of patients but thromboprophylaxis was prescribed in 22.5% of the cases, LMWH in 18.1%, and Rivaroxaban in 3.7%. Hemorrhagic events occurred in eight patients (0.3%): five patients showed minor hemorrhagic events and three patients showed major ones (0.14%).ConclusionsOur study showed that the incidence of thromboembolic complications is very low in COVID-19 ambulatory patients. Paradoxically, there is an over prescription of thrombo-prophylaxis in this population.

An initiative to improve adherence to guidelines for thromboprophylaxis among high-risk gynecologic oncology patients receiving outpatient chemotherapy (293)

Objectives: Pharmacologic thromboprophylaxis is recommended for high-risk gynecologic oncology patients with a Khorana score (KS) ≥ 2 receiving outpatient chemotherapy. Our objective was to evaluate the impact of a quality improvement (QI) project designed to increase KS calculation and documentation of thromboprophylaxis eligibility for patients initiating outpatient chemotherapy. Methods: In January 2021, the Society of Gynecologic Oncology endorsed guidelines recommending thromboprophylaxis for gynecologic oncology patients with a KS ≥ 2 receiving outpatient chemotherapy. The primary barriers to the implementation of these guidelines at the author’s institution included provider awareness, KS calculation, and documentation of eligibility. Starting June 2021, a KS calculator and associated thromboprophylaxis algorithm were incorporated into outpatient documentation templates. Eligible patients included those with gynecologic malignancies initiating a new chemotherapy regimen from January to September 2021. The percentages of patients for whom KS and thromboprophylaxis eligibility were documented at the start of the first cycle pre- and post-QI initiative were compared using the Chi-square test. The percentages of eligible patients who were offered and initiated thromboprophylaxis (apixaban 2.5 mg twice daily) in accordance with the algorithm were also assessed. Results: There were 119 total new chemotherapy cases identified in the study time frame: 61 pre-QI (51.3%) and 58 post-QI (48.7%). Of these, 34.4% (21/61) and 34.5% (20/58) were eligible for thromboprophylaxis pre- and post-QI, respectively. Table 1 demonstrates percentages of patients for whom KS calculation and thromboprophylaxis eligibility were documented prior to cycle 1 initiation. There was a statistically significant increase in documentation following QI initiation (pre-QI: 8/61 [13.1%], post-QI: 38/58 [65.5%]; p < 0.001). Of those who were eligible, 9.5% were offered thromboprophylaxis pre-QI (2/21) and 65% post-QI (13/20) (p < 0.001). Table 1 describes the percentages of eligible patients initiating thromboprophylaxis in accordance with the recommendations. There were no new venous thromboembolic events among eligible patients’ pre-QI and one post-QI. Conclusions: Over one-third of gynecologic cancer patients starting outpatient chemotherapy met eligibility criteria for pharmacologic thromboprophylaxis. Following the implementation of our QI initiative, there was an increase in KS calculation, documentation, and appropriate prescription of thromboprophylaxis among eligible patients. Studies are ongoing to measure patient adherence to pharmacologic thromboprophylaxis and to determine if adherence to thromboprophylaxis guidelines improves outcomes in this population. Objectives: Pharmacologic thromboprophylaxis is recommended for high-risk gynecologic oncology patients with a Khorana score (KS) ≥ 2 receiving outpatient chemotherapy. Our objective was to evaluate the impact of a quality improvement (QI) project designed to increase KS calculation and documentation of thromboprophylaxis eligibility for patients initiating outpatient chemotherapy. Methods: In January 2021, the Society of Gynecologic Oncology endorsed guidelines recommending thromboprophylaxis for gynecologic oncology patients with a KS ≥ 2 receiving outpatient chemotherapy. The primary barriers to the implementation of these guidelines at the author’s institution included provider awareness, KS calculation, and documentation of eligibility. Starting June 2021, a KS calculator and associated thromboprophylaxis algorithm were incorporated into outpatient documentation templates. Eligible patients included those with gynecologic malignancies initiating a new chemotherapy regimen from January to September 2021. The percentages of patients for whom KS and thromboprophylaxis eligibility were documented at the start of the first cycle pre- and post-QI initiative were compared using the Chi-square test. The percentages of eligible patients who were offered and initiated thromboprophylaxis (apixaban 2.5 mg twice daily) in accordance with the algorithm were also assessed. Results: There were 119 total new chemotherapy cases identified in the study time frame: 61 pre-QI (51.3%) and 58 post-QI (48.7%). Of these, 34.4% (21/61) and 34.5% (20/58) were eligible for thromboprophylaxis pre- and post-QI, respectively. Table 1 demonstrates percentages of patients for whom KS calculation and thromboprophylaxis eligibility were documented prior to cycle 1 initiation. There was a statistically significant increase in documentation following QI initiation (pre-QI: 8/61 [13.1%], post-QI: 38/58 [65.5%]; p < 0.001). Of those who were eligible, 9.5% were offered thromboprophylaxis pre-QI (2/21) and 65% post-QI (13/20) (p < 0.001). Table 1 describes the percentages of eligible patients initiating thromboprophylaxis in accordance with the recommendations. There were no new venous thromboembolic events among eligible patients’ pre-QI and one post-QI. Conclusions: Over one-third of gynecologic cancer patients starting outpatient chemotherapy met eligibility criteria for pharmacologic thromboprophylaxis. Following the implementation of our QI initiative, there was an increase in KS calculation, documentation, and appropriate prescription of thromboprophylaxis among eligible patients. Studies are ongoing to measure patient adherence to pharmacologic thromboprophylaxis and to determine if adherence to thromboprophylaxis guidelines improves outcomes in this population.

Perioperative Thromboprophylaxis Is Associated With Lower Risk of Venous Thromboembolism After Knee Arthroscopy

To determine the rate of symptomatic venous thromboembolism (VTE) among patients undergoing arthroscopic knee procedures, risk factors associated with postoperative VTE, and current perioperative thromboprophylaxis prescription patterns associated with this population in the United States. Medical records for patients ≥18 years of age were queried from the Mariner database using Current Procedural Terminology codes for knee arthroscopy performed in the United States from 2010 to 2020 in this cross-sectional study. Patients who received thromboprophylaxis and those diagnosed with VTE, including deep-vein thrombosis or pulmonary embolism, within 90 days of surgery were identified using International Classification of Diseases and National Drug Codes. Two multivariable logistic regression models were used to identify VTE risk factors and likelihood of perioperative thromboprophylaxis. Covariates included procedure type, age, oral contraceptive pill (OCP) use, and medical comorbidities. A total of 718,289 patients met inclusion criteria and 7,618 patients (1.06%) experienced VTE, including deep-vein thrombosis (n= 6,394, 0.9%) and/or pulmonary embolism (n= 2,211, 0.3%). A total of 10,769 patients (1.5%) filled perioperative thromboprophylaxis, including aspirin (n= 5,353, 0.7%), low-molecular-weight heparin (n= 4,563, 0.6%), and oral factor Xa inhibitors (n= 947, 0.1%). Perioperative thromboprophylaxis was associated with decreased odds of experiencing VTE (adjusted odds ratio [aOR] 0.65, 95% confidence interval [CI] 0.51-0.80). Procedure types categorized as moderate-to-greater risk were associated with increased odds of VTE (aOR 1.42, 95% CI 1.34-1.50). OCP use (aOR 1.63, 95% CI 1.38-1.91), obesity (aOR 1.17, 95% CI 1.11-1.24), renal disease (aOR 1.33, 95% CI 1.18-1.50) and congestive heart failure (aOR 1.30, 95% CI 1.13-1.50) were associated with increased odds of VTE. While the overall rate of symptomatic VTE following knee arthroscopy remains low, procedure types that are more complex and generally require restrictive rehabilitation protocols, OCP use, obesity, renal disease, and congestive heart failure are associated with increased odds of postoperative VTE. Conversely, the use of perioperative thromboprophylaxis is associated with significantly lower VTE risk. III, retrospective comparative prognostic trial.

Poster 222: Venous Thromboembolism Risk factors and Prophylaxis Patterns in Knee Arthroscopy: A Large Database Study

Objectives:Incidence of venous thromboembolism (VTE) after knee arthroscopy is reportedly low, but rates vary significantly across literature. Current guidelines recommend against routine perioperative thromboprophylaxis, but prescribing practices and VTE risk factors are poorly understood.Methods:Medical records for patients ≥18 years of age were queried from the Pearl Diver database using CPT codes for arthroscopic knee procedures. Patients with a previous diagnosis of VTE or hyper-coagulable disorder were excluded from analyses. Procedures were grouped by rehabilitation protocols, with restrictive procedures requiring a period of non-weightbearing or postoperative immobilization. Patients who received perioperative thromboprophylaxis were identified. Patients diagnosed with VTE, including pulmonary embolism and/or deep vein thrombosis, within 90 days of surgery were identified using International Classification of Diseases (ICD) codes. Multivariable logistic regression models were utilized to identify VTE risk factors and likelihood of thromboprophylaxis prescription. Covariates included age, restrictive rehabilitation protocols, oral contraceptive pill (OCP) use, and medical comorbidities.Results:A total of 718,289 patients underwent knee arthroscopy from 2011 to 2020. 10,769 patients (1.5%) received perioperative thromboprophylaxis, including aspirin (n=5,353, 0.7%), low molecular weight heparin (n=4,563, 0.6%) and factor Xa inhibitors (n=947, 0.1%). A total of 7,618 patients (1.1%) experienced VTE. Perioperative prophylaxis was associated with decreased odds of experiencing VTE (adjusted odds ratio [aOR] = 0.64, 95% confidence interval [CI] = 0.51 to 0.79) (Table 1). Restrictive procedure type was associated with increased odds of experiencing VTE (aOR =1.42, 95% CI = 1.34 to 1.50) and receiving prophylaxis (aOR=1.95, 95% CI = 1.87 to 2.05). OCP use (aOR = 1.63, 95% CI = 1.37 to 1.91), renal disease (aOR = 1.33, 95% CI = 1.18 to 1.50) and congestive heart failure (aOR = 1.30, 95% CI = 1.13 to 1.49) were associated with increased odds of VTE. Tobacco use was associated with increased odds of VTE (aOR = 1.12, 95% CI 1.03 to 1.22), but decreased odds of receiving perioperative prophylaxis (aOR = 0.84, 95% CI 0.78 to 0.91). Malignancy was associated with increased odds of receiving prophylaxis (aOR = 1.18, 95% CI 1.09 to 1.29) but not with increased odds of VTE.Conclusions:Procedures with restrictive rehabilitation protocols, OCP use, renal disease, and congestive heart failure are associated with increased odds of VTE following knee arthroscopy. Conversely, the use of perioperative thromboprophylaxis is associated with significantly lower odds of VTE. Risk factors for postoperative VTE are not always correlated with increased likelihood of receiving perioperative thromboprophylaxis. Patients with a tobacco use history may be an at-risk population that can be better selected for thromboprophylaxis when clinically appropriate.Table 1.Multivariable Logistic Model of VTE and Perioperative Thromboprophylaxis Odds

Evaluation of the Khorana Predictive Thrombotic Risk and Thromboprophylaxis Score in Cancer Patients in a Third Level Hospital

IntroductionCurrent clinical guidelines do not recommend the routine use of thromboprophylaxis in cancer primary unselected patients. Identifying cancer patients who could be beneficiaries of thrombotic prophylaxis is a real challenge. We aimed to analyse the application of Khorana score in cancer patients. We also tried to evaluate the prescription of primary thromboprophylaxis in cancer patients at risk of venous thromboembolic disease (VTED). MethodsA retrospective observational study of survival of hospitalised patients diagnosed with pulmonary embolism (PE) at the Hospital Central de la Defensa from January 2009 to March 2018. They were stratified into tumour PE (TPE) and non-tumour PE (nTPE). A case-control study was also carried out by TPE patients and non PE cancer patients (nPEC). Results108 patients were diagnosed with TPE, 260 nTPE and 324 nPEC. Gynaecological tumours were the most frequent (23.1%), followed by lung, digestive and urological cancer (20.4% each) in the TPE group. Death risk was 1.9 times higher in cancer patients (95% CI: 1.23–2.8) (p<0.001). Khorana score was ≥3 points in 9.7% of TPE and 3.1% of nPEC compared to 26.2% of TPE and 9.9% of nPEC with Khorana score ≥2 points (p<0.001). 7.4% of TPE patients received thromboprophylaxis. Khorana score in TPE patients without thromboprophylaxis was ≥3 points in the 9% and ≥2 points in the 24%. ConclusionsThere is an underutilisation of thromboprophylaxis in our cancer patients and mainly in those with high risk of VTED, as well as poor adherence to the Khorana score. More studies are needed to validate these findings and to optimise predictive strategies in the management of these patients.

Venous thromboembolism risk assessment and prophylaxis in hospitalised medical patients in the Cape Town metropole, South Africa

Background. Venous thromboembolism (VTE) is regarded as the most preventable cause of inpatient death in hospital settings globally. VTE can be prevented through the provision of non-pharmacological and/or pharmacological thromboprophylaxis following individualised risk screening. The Caprini risk assessment model (RAM) offers a validated and well-established approach for VTE risk assessment in medical inpatients. Literature findings describe a trend towards inappropriate and under-prescribing of thromboprophylaxis in this population. Together with concerns regarding clinicians’ perceived importance of VTE risk assessment, the need to clarify these aspects of practice is evident. Objectives. To describe VTE risk assessment and prophylaxis practices of medical practitioners in public sector hospitals in Western Cape Province, South Africa (SA). Methods. A retrospective, cross-sectional study design was employed in the medical wards of two district hospitals and one regional hospital in the Cape Town metropole, Western Cape. Medical folders of adult medical inpatients admitted between January and July 2020 were reviewed to assess VTE risk using the Caprini RAM. Thromboprophylaxis therapy prescribed and contraindications to chemoprophylaxis were also evaluated. Results. Of 380 patients included in the review, 51.6% were female, and the average age was 52.1 years (range 18 - 96); 21.3% had their weight recorded, while none had their height documented. Infectious disease was the predominant diagnosis (49.2%) detected in the sample. Common VTE risk factors identified included bed rest/restricted mobility for &lt;72 hours (76.3%) and serious infection (67.4%). A total of 97.1% of patients (n=369) were found to be at moderate or higher risk of VTE (Caprini score ≥2). Of this at-risk group, 24.1% were eligible to receive chemoprophylaxis, yet no prescription for thromboprophylaxis was identified. Seventy percent of patients (n=266) were prescribed chemoprophylaxis, with enoxaparin accounting for 98.5% of regimens. Contraindications to chemoprophylaxis were recorded in 13.4% of patients. Conclusions. Although rates of VTE prophylaxis in medical inpatients may be improving, thromboprophylaxis still remains critically underutilised in this population. This study highlighted a consequence of this trend, with inappropriate chemoprophylaxis prescribing becoming more evident. Mechanical prophylaxis prescribing in medical inpatients is lacking, despite the associated benefits. RAMs should be adapted for the SA setting, where infectious diseases are prevalent. Future research should assess RAM use by clinicians, as this could provide insight into improving RAM uptake and thromboprophylaxis prescribing.

Reasons for non-adherence to thromboprophylaxis prescribing guidelines in atrial fibrillation in Western Australia: A qualitative descriptive study of general practitioners' views

BackgroundA significant proportion of the atrial fibrillation (AF) population attending Australian primary care is not receiving guideline-adherent oral anticoagulant (OAC) treatment. This study aimed to explore reasons for non-adherence to thromboprophylaxis guidelines in AF from the perspectives of general practitioners (GPs) and to map these reasons to the Capability, Opportunity, Motivation-Behaviour (COM-B) model to identify potential opportunities to support practice change. MethodsAn exploratory qualitative descriptive study among GPs practising in Western Australia was conducted using semi-structured interviews, from November 2020 to February 2021. The Framework Method was employed to facilitate thematic analysis, using NVivo software. Interview responses were also mapped to the COM-B model. ResultsNine of the 10 GPs initially consented participated in the semi-structured interview (Male = 56%, median age = 52 years, data saturation reached with 6 participants). Two themes emerged from analysis of the interview transcripts: (1) GPs' decision-making process and (2) Patient refusal to take OACs. The COM-B model mapping identified behavioural factors that could impact adherence: capability (GPs' knowledge and understanding of AF guideline recommendations), opportunity (access to a cardiologist, and patients' refusal to take OACs), and motivation (using formal bleeding risk assessment tools). ConclusionGPs identified various reasons contributing to non-adherence to thromboprophylaxis guidelines in patients with AF. Multifaceted interventions should consider behavioural opportunities to improve adherence, including education and training, electronic decision support, clinical audits by allied health professionals, partnership between general practices and local hospitals, and cardiologist-led interventions to support GPs. Further studies are needed to capture patients' reasons for refusing OACs.

408 The Swiss Cheese Effect: Following Lower Limb Emergency Admissions Through Hospital

Abstract Introduction The Swiss cheese model analyses failure in a system: when holes align this creates ‘a trajectory of accident opportunity’. In healthcare this could translate to morbidity and/or mortality of patients. We investigated potential points of failure in treating lower limb injury patients through their hospital journey. Three points were investigated: (1) prescription of venous thrombo-embolism (VTE) prophylaxis, (2) operation note information and legibility (3) time delay in post-operative blood tests. Method A total of 105 patients of emergency lower limb surgical patients were identified retrospectively from two centres across the North West Region between the 31/07/20 and 21/11/20. Data was collected on (1) prescription of thrombo-prophylaxis, (2) information recorded, and legibility of operation notes as per RCSEng and (3) time delay in post-operative full blood count when compared to operation note recommendation. Results We found that between 10-55% of patients were prescribed anti-embolism stockings versus 100% given chemical anti-coagulation on day 1 of admission. Of a total of 23 data points, the mean number of points missing on operative notes was 4.90 (range: 2-10). A total of 82.5% handwritten operation notes were deemed legible. Post-operative full blood counts were ordered in 83.3% of patients, with the first order ranging between 1-5 days post operatively. Conclusions The cumulative effect of having these errors at all three points greatly increases the chance of morbidity/mortality of patients. Our experience demonstrates a failure to meet trust and Royal College of Surgeon’s guidelines. We aim to re-audit this nationally with our planned intervention.

A known unknown? Pharmacological prevention of venous thromboembolism in nursing home residents.

A known unknown? Pharmacological prevention of venous thromboembolism in nursing home residents.

Clinical Outcomes in Burns Patients with Early Venous Thromboembolism Prophylaxis Compared with Late-Anticoagulated Patients: A Retrospective Study

The aim of this study was to describe the timing of venous thromboembolism diagnosis in patients with severe burns and determine the relationship between venous thromboembolism prophylaxis and venous thromboembolism development in a large trauma hospital. A retrospective cohort study over 10 years from 2009 to 2019 was conducted. Records of 226 patients with &gt;20% total body surface area burns were surveyed, and 20 patients with symptoms suggestive of venous thromboembolism had a diagnosis of VTE confirmed on imaging. Enoxaparin was the most common primary thromboprophylaxis (85%, n = 192), followed by heparin (13.71%, n = 31) and sequential compression devices (0.88%, n = 2). Compared with patients who did not develop a venous thromboembolism, patients who developed a venous thromboembolism had a mean difference in time from admission to thromboprophylaxis prescription of 1.72 days (95% CI = −1.50 to 4.92, p &gt; 0.05) and 10.51 days in those who developed a pulmonary embolus (mean difference = 10.51, 95% CI = 3.73 to 17.32, p = 0.0006). A threshold of 4 days was identified by which 96% of patients who never developed venous thromboembolism during admission were prescribed prophylaxis, compared with 32% of those who developed a pulmonary embolus. No bleeding or adverse events were recorded. Timely prescription of thromboprophylaxis in patients with severe burns is critical in reducing venous thromboembolism incidence. Avoidance of delay post injury is especially critical in preventing venous thromboembolism development. Guidelines on thromboprophylaxis must be considered on an individualised patient basis, considering likely surgical requirements and obesity.