Prophylaxis In Medical Patients Research Articles

Converting IMPROVE bleeding and VTE risk assessment models into a fast-and-frugal decision tree for optimal hospital VTE prophylaxis

AbstractCurrent hospital venous thromboembolism (VTE) prophylaxis for medical patients is characterized by both underuse and overuse. The American Society of Hematology (ASH) has endorsed the use of risk assessment models (RAMs) as an approach to individualize VTE prophylaxis by balancing overuse (excessive risk of bleeding) and underuse (risk of avoidable VTE). ASH has endorsed IMPROVE (International Medical Prevention Registry on Venous Thromboembolism) risk assessment models, the only RAMs to assess short-term bleeding and VTE risk in acutely ill medical inpatients. ASH, however, notes that no RAMs have been thoroughly analyzed for their effect on patient outcomes. We aimed to validate the IMPROVE models and adapt them into a simple, fast-and-frugal (FFT) decision tree to evaluate the impact of VTE prevention on health outcomes and costs. We used 3 methods: the “best evidence” from ASH guidelines, a “learning health system paradigm” combining guideline and real-world data from the Medical University of South Carolina (MUSC), and a “real-world data” approach based solely on MUSC data retrospectively extracted from electronic records. We found that the most effective VTE prevention strategy used the FFT decision tree based on an IMPROVE VTE score of ≥2 or ≥4 and a bleeding score of <7. This method could prevent 45% of unnecessary treatments, saving ∼$5 million annually for patients such as the MUSC cohort. We recommend integrating IMPROVE models into hospital electronic medical records as a point-of-care tool, thereby enhancing VTE prevention in hospitalized medical patients.

Evaluation of the use of low-molecular-weight heparin for venous thromboembolism prophylaxis in medical patients.

Venous thromboembolism (VTE) complicates a significant proportion of medical admissions. As well as increasing patient morbidity, pulmonary embolism is one of the commonest preventable causes of in-hospital death. An increase in the use of pharmacological preventive measures has been advocated in recent years. South African (SA) and international guidelines have been published in an effort to promote the safe use of VTE prophylaxis. To describe adherence to both local and international recommendations for VTE prophylaxis in an SA hospital with regard to appropriateness of the decision to prescribe or withhold low-molecular-weight heparin (LMWH), and to observe the practice of dose adjustment in special population groups. This was a prospective, observational study, and data were collected from consenting adults admitted to the medical wards. We assessed the patients' VTE risk, bleeding risk and the presence of contraindications at the time of LMWH prescription as well as the dose prescribed, specifically taking into consideration adjustment for renal dysfunction and obesity. Three hundred and fifty-two patients were enrolled, of whom 51.4% were male and 58.5% received LMWH. Primary outcomes. The appropriate overall decision according to both SA and international guidelines was made in 254 cases (72.2%). The inappropriate decision according to both guidelines was made in 79 cases (22.4%) and the appropriate decision according to one guideline only was made in 18cases (5.1%), while 1 case (0.3%) was not categorised. Contraindications to VTE prophylaxis were present in 35 patients (9.9%), but 9 of these patients nevertheless received LMWH. An incorrect dose was prescribed in 36 cases (17.5%), the most common reason being an inappropriate reduction in the dose in mild renal dysfunction. Other medications that may have increased bleeding risk were prescribed in 46 patients who received LMWH (22.3%). Mechanical prophylaxis was indicated in 25 (7.1%) of the total sample; however, none received this. Overall adherence to published guidelines for VTE prophylaxis has improved compared with other published reviews on the topic, but documentation of patients' VTE risk in files is poor. Overuse in low-risk patients may be an unintended consequence of the widespread advocacy of LMWH use in hospital, highlighting the importance of adequate VTE risk stratification. Incorrect dosing in special population groups is an issue that needs to be addressed, as is non-utilisation of mechanical prophylaxis methods.

Venous Thromboembolism Prophylaxis in Acute Medically Ill Patients: A Retrospective Cohort Study

Background and Aims Venous thromboembolism (VTE) is considered as a preventable cause of death for hospitalized patients. Current guidelines recommend pharmacologic prophylaxis for medical patients considered high risk for VTE, despite failure of studies to show reduction in mortality. We aimed to assess the benefit and safety of VTE prophylaxis in acutely ill medical patients hospitalized in internal medicine wards. Methods Retrospective cohort study of all patients admitted to the internal medicine and acute geriatric departments, with an admission lasting more than 48 hours, during 2012-2018. Patients who received pharmacologic prophylaxis were compared to those who did not. The primary outcome was 30-day mortality. Secondary outcomes were the 90 day incidence of pulmonary embolism (PE), symptomatic deep vein thrombosis (DVT), and major bleeding. Propensity-weighted logistic multivariable analysis was performed. Results A total of 18890 patient-unique episodes were included in the analysis. Of them 3206 (17%) received prophylaxis. A total of 1309 (6.9%) died. 540/1309 (41.3%) of those who received VTE prophylaxis died and 769/1309 (58.7%) of those who did not receive prophylaxis died. VTE Prophylaxis was not associated with a reduction in mortality, multivariate-adjusted OR 0.99 (95% CI 0.84-1.14). One hundred and forty two patients (0.7%) developed VTE. The frequency of VTE among patients who received VTE prophylaxis was 31% (44/142) compared with 69% (98/142) in patients who did not receive prophylaxis. The frequency of VTE in patients who had a Padua score ≥4 and received VTE prophylaxis, was 1.9% (30/1573) compared with 1.6% (44/2797) in those with a Padua score ≥4 who did not receive prophylaxis. 74/142 (52.1%) of patients with VTE had a Padua score ≥4, 44/1309 (1.4%) of those who received VTE prophylaxis and 98/15864 (0.6%) of those who did not. VTE Prophylaxis was not associated with reduction in VTE in the whole cohort, multivariable-adjusted OR 1.09 (95% CI 0.52-2.29). VTE prophylaxis was associated with an increase in major bleeding (multivariable-adjusted OR 1.24, 95% CI 1.04-1.48) Conclusion The current practice of routinely administering VTE prophylaxis to medically ill patients considered at high risk for VTE, resulted in a high risk for bleeding a without clear clinical benefit, and should be reassessed. Disclosures No relevant conflicts of interest to declare.

Compliance with current VTE prophylaxis guidelines and risk factors linked to complications of VTE prophylaxis in medical inpatients: a prospective cohort study in a Spanish internal medicine department

ObjectivesTo evaluate the degree of compliance with the current guidelines regarding venous thromboembolism (VTE) prophylaxis in medical patients during admission and to identify risk factors linked to complications of VTE...

Could a Coagulation Nurse Liaison Improve Compliance With Venous Thromboembolism Prophylaxis in Medical Patients?

Medical patients worldwide are undertreated with venous thromboembolism prophylaxis. Our hypothesis was that the rate of prophylactic anticoagulation therapy for high-risk patients would improve with the use of a coagulation nurse liaison. Six months after appointing a nurse for this role, prophylaxis rates significantly improved, and patients were more likely to receive appropriate thromboprophylaxis. A coagulation nurse liaison substantially improves thromboprophylaxis in a medical ward.

Predictors of thromboprophylaxis in hospitalised medical patients. Explicit ASsessment of Thromboembolic RIsk and Prophylaxis for Medical PATients in SwitzErland (ESTIMATE).

Both, underuse and overuse of thromboprophylaxis in hospitalised medical patients is common. We aimed to explore clinical factors associated with the use of pharmacological or mechanical thromboprophylaxis in acutely ill medical patients at high (Geneva Risk Score ≥ 3 points) vs low (Geneva Risk Score < 3 points) risk of venous thromboembolism. Overall, 1,478 hospitalised medical patients from eight large Swiss hospitals were enrolled in the prospective Explicit ASsessment of Thromboembolic RIsk and Prophylaxis for Medical PATients in SwitzErland (ESTIMATE) cohort study. The study is registered on ClinicalTrials.gov, number NCT01277536. Thromboprophylaxis increased stepwise with increasing Geneva Risk Score (p< 0.001). Among the 962 high-risk patients, 366 (38 %) received no thromboprophylaxis; cancer-associated thrombocytopenia (OR 4.78, 95 % CI 2.75-8.31, p< 0.001), active bleeding on admission (OR 2.88, 95 % CI 1.69-4.92, p< 0.001), and thrombocytopenia without cancer (OR 2.54, 95 % CI 1.31-4.95, p=0.006) were independently associated with the absence of prophylaxis. The use of thromboprophylaxis declined with increasing severity of thrombocytopenia (p=0.001). Among the 516 low-risk patients, 245 (48 %) received thromboprophylaxis; none of the investigated clinical factors predicted its use. In conclusion, in acutely ill medical patients, bleeding and thrombocytopenia were the most important factors for the absence of thromboprophylaxis among high-risk patients. The use of thromboprophylaxis among low-risk patients was inconsistent, without clearly identifiable predictors, and should be addressed in further research.

Pneumonia and venous thromboembolism: Is the evidence catching up with the guidelines?

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The Use of Low Molecular Weight Heparin for Venous Thromboembolism Prophylaxis in Medical Patients: How Much Are We Adherent to the Guidelines?

Background: Venous thromboembolism (VTE) is a common complication seen during or after hospitalization that manifests as deep venous thrombosis (DVT) and/or pulmonary embolism (PE). PE is considered the commonest preventable cause of death during and/or after hospitalization. Thus, pharmacological and mechanical methods are used to prevent VTE in hospitalized patients. Despite the availability of guidelines for VTE prophylaxis, it is crucial to assess the adherence and adaptation of the institution to these guidelines. Purpose: This study aimed to investigate adherence to the American College of Chest Physicians (ACCP) 2012 VTE prophylaxis guidelines in hospitalized medical patients in a tertiary care hospital in the United Arab Emirates. Methods: An observational prospective design was utilized in this study. To achieve the purpose, primary and secondary end points were identified to be the core of the investigation. The primary end points were: the incidence of bleeding, VTE, and cardiovascular events. While the secondary end points were: dose and indication validity for prophylaxis, VTE and bleeding risk assessments, adverse drug events (ADE) other than bleeding, appropriate monitoring when on low molecular weight heparin (LMWH) and the presence of contraindication at the time of prescribing LMWH. Results: 16 patients (20%) out of the total 80 met one or more of the primary end points. The vast majority of patients (81.25%) developed bleeding, while VTE was seen in one case only during hospitalization. 11 patients (13.75%) received LMWH while a contraindication was present. 15 patients (18.75%) who were prescribed LMWH had an International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) bleeding risk score of ≥7. However, 5 out of 13 patients (38.46%) who developed bleeding had a bleeding score of ≥7, and the relationship between bleeding score of ≥7 and the development of bleeding was statistically significant (p = 0.047). When investigating the doses that were utilized, 40% were prescribed an inappropriate dose. Conclusion: Various factors played a role in the inappropriateness of VTE prophylaxis such as; poor adherence to VTE guidelines, inappropriate dosing and monitoring, and not evaluating the bleeding risk. Hence, to be able to achieve effective VTE prophylaxis, these factors need to be addressed through adherence to and adaptation of the ACCP 2012 VTE prophylaxis guidelines.

The effect of clinical decision support on adherence to thrombosis prophylaxis guidelines in medical patients; A single center experience

IntroductionVenous thromboembolism (VTE) is an underestimated health problem. The administration of low molecular weight heparins (LMWH) to the appropriate patients dramatically decreases VTE incidence. Clinical decision support (CDS) might contribute to thrombosis prophylaxis guideline adherence. MethodsA computerized integrated risk score program was used to estimate VTE and bleeding risk of nonsurgical patients. A VTE risk score of ≥4 resulted in an advice to administer LMWH. We selected 64 medical patients before the introduction of CDS (T0) and 64 patients after the introduction (T1). We compared guideline compliance between these groups using chi2 tests. ResultsNo difference between groups was found; Adherence to the guidelines at T0 was 59.4%, the same percentage of 59.4% was found at T1. To evaluate the effect of the introduction of CDS in terms of under and overtreatment we compared the prevalence of over and under treatment at T1 and T0. The OR for receiving under treatment at T1 compared to T0 is 0.48 (95% CI: 0.18-1.30), p=0.14. The OR for overtreatment at T1 compared to T0 is 1.66 (95% CI: 0.74-3.73), p=0.22 ConclusionWe found no improvement in guideline adherence towards anti thrombotic prophylaxis in medical patients after the introduction of CDS in this pilot study. There was however a non-significant shift towards over treatment. Possible explanations for these results are the increased awareness of the risk for thromboembolism induced by the study, suboptimal use of CDS and deviation from CDS advice caused by patient’s preferences.

Multicentre validation of the Geneva Risk Score for hospitalised medical patients at risk of venous thromboembolism

There is a need to validate risk assessment tools for hospitalised medical patients at risk of venous thromboembolism (VTE). We investigated whether a predefined cut-off of the Geneva Risk Score, as compared to the Padua Prediction Score, accurately distinguishes low-risk from high-risk patients regardless of the use of thromboprophylaxis. In the multicentre, prospective Explicit ASsessment of Thromboembolic RIsk and Prophylaxis for Medical PATients in SwitzErland (ESTIMATE) cohort study, 1,478 hospitalised medical patients were enrolled of whom 637 (43%) did not receive thromboprophylaxis. The primary endpoint was symptomatic VTE or VTE-related death at 90 days. The study is registered at ClinicalTrials.gov, number NCT01277536. According to the Geneva Risk Score, the cumulative rate of the primary endpoint was 3.2% (95% confidence interval [CI] 2.2-4.6%) in 962 high-risk vs 0.6% (95% CI 0.2-1.9%) in 516 low-risk patients (p=0.002); among patients without prophylaxis, this rate was 3.5% vs 0.8% (p=0.029), respectively. In comparison, the Padua Prediction Score yielded a cumulative rate of the primary endpoint of 3.5% (95% CI 2.3-5.3%) in 714 high-risk vs 1.1% (95% CI 0.6-2.3%) in 764 low-risk patients (p=0.002); among patients without prophylaxis, this rate was 3.2% vs 1.5% (p=0.130), respectively. Negative likelihood ratio was 0.28 (95% CI 0.10-0.83) for the Geneva Risk Score and 0.51 (95% CI 0.28-0.93) for the Padua Prediction Score. In conclusion, among hospitalised medical patients, the Geneva Risk Score predicted VTE and VTE-related mortality and compared favourably with the Padua Prediction Score, particularly for its accuracy to identify low-risk patients who do not require thromboprophylaxis.

Prevention of venous thromboembolism in acutely ill medical patients after the results of recent trials with the new oral anticoagulants

Venous thromboembolism (VTE) is a common potentially life-threatening complication in acutely ill medical patients; over 70 % of the fatal episodes of pulmonary embolism during hospitalization occur in non-surgical patients. In the absence of thromboprophylaxis, the incidence of venographically detected deep vein thrombosis is about 15 % in medical patients. Several trials and meta-analyses have clearly demonstrated the prophylactic role of unfractionated heparin, low molecular weight heparin and fondaparinux. Although over the past few years the knowledge of epidemiology, clinical features and prophylaxis in medical patients has significantly improved, there remain a number of controversial areas that require further investigation. Newer VTE risk assessment models have been proposed to select high risk hospitalized medical patients, but they still require external validation; scarce data are available to stratify patients to identify their individual bleeding risk. The optimal duration of thromboprophylaxis in medical patients is still a matter of debate; currently, extended prophylaxis after discharge is not recommended, but it may be required for subgroup of patients with persistently high VTE risk and a negligible risk of bleeding. Based on the results of recent studies, the new oral anticoagulants appear to have a very limited role, if any. However, a better risk stratification of patients who have a persistently increased risk of VTE is warranted to improve the risk to benefit profile of any anticoagulant drug to be used in this setting.

Osteoporosis prophylaxis in medical patients taking corticosteroids

Osteoporosis prophylaxis in medical patients taking corticosteroids

High incidence of venous thromboembolism despite electronic alerts for thromboprophylaxis in hospitalised cancer patients

Many cancer patients are at high risk of venous thromboembolism (VTE) during hospitalisation; nevertheless, thromboprophylaxis is frequently underused. Electronic alerts (e-alerts) have been associated with improvement in thromboprophylaxis use and a reduction of the incidence of VTE, both during hospitalisation and after discharge, particularly in the medical setting. However, there are no data regarding the benefit of this tool in cancer patients. Our aim was to evaluate the impact of a computer-alert system for VTE prevention in patients with cancer, particularly in those admitted to the Oncology/Haematology ward, comparing the results with the rest of inpatients at a university teaching hospital. The study included 32,167 adult patients hospitalised during the first semesters of years 2006 to 2010, 9,265 (28.8%) with an active malignancy. Appropriate prophylaxis in medical patients, significantly increased over time (from 40% in 2006 to 57% in 2010) and was maintained over 80% in surgical patients. However, while e-alerts were associated with a reduction of the incidence of VTE during hospitalisation in patients without cancer (odds ratio [OR] 0.31; 95% confidence interval [CI], 0.15-0.64), the impact was modest in cancer patients (OR 0.89; 95% CI, 0.42-1.86) and no benefit was observed in patients admitted to the Oncology/Haematology Departments (OR 1.11; 95% CI, 0.45-2.73). Interestingly, 60% of VTE episodes in cancer patients during recent years developed despite appropriate prophylaxis. Contrary to the impact on hospitalised patients without cancer, implementation of e-alerts for VTE risk did not prevent VTE effectively among those with malignancies.

Risk-assessment models for predicting venous thromboembolism among hospitalized non-surgical patients: a systematic review

Venous thromboembolism (VTE) prophylaxis is suboptimal in American hospitals despite long-standing evidence-based recommendations. Data from observational studies indicate a lower uptake of effective prophylaxis in patients hospitalized with medical versus surgical conditions. Reluctance to use prophylaxis in medical patients has been attributed to difficulty in identifying at-risk patients and balancing risks of bleeding against occurrence of VTE. Several risk-assessment models (RAMs) have been proposed to assist physicians in identifying non-surgical patients who need prophylaxis. We conducted a systematic review of published RAMs, based on objective criteria, to determine whether any RAM is validated sufficiently to be employed in clinical practice. We identified 11 RAMs, six derived from primary data and five based on expert opinion. The number, types, and strength of association of VTE risk predictors were highly variable. The variability in methods and outcome measurement precluded pooled estimates of these different models. Published RAMs for VTE lack generalizability and adequate validation. As electronic health records become more ubiquitous, validated dynamic RAMs are needed to assess VTE risk at the point-of-care in real time.

Benefits versus risks of pharmacological prophylaxis to prevent symptomatic venous thromboembolism in unselected medical patients revisited. Meta-analysis of the medical literature

A significant proportion of the outcomes reported in trials assessing venous thromboembolism (VTE) prophylaxis in medical patients are related to asymptomatic events found on routine imaging studies. The implications of these events are controversial. Moreover, such trials did not always reflect the patient mix in today's internal medicine departments. We summarized the evidence assessing the rate of symptomatic VTE events and the benefit of pharmacological prophylaxis in unselected medical patients, and formally evaluated the benefit versus risk of this intervention. We searched MEDLINE, EMBASE and CENTRAL until June 2011 for studies that prospectively followed cohorts of medical patients and assessed the rates of VTE, and randomized controlled trials reporting the effect of prophylaxis on these events, at 3 weeks and 3 months. Eight trials were included. The rates of symptomatic VTE were 0.69 and 3.7 % for short term and long term follow-up periods, respectively. In the interventional meta-analysis, the odds ratio (OR) for overall mortality and for symptomatic VTE at 3 weeks were 0.93 and 0.59, favouring intervention. The OR for major bleeding at 3 weeks was 2.0, favouring no intervention. None of these results were statistically significant. The number needed to treat to prevent one overt VTE event was 292, while the number needed to treat for an additional major bleeding was 336. In unselected medical patients, the rate of symptomatic VTE is lower than the reported overall VTE rate, and the benefit to risk ratio of pharmacological intervention for alleviating this condition in at-risk medical inpatient is questionable. Further specifying the population at risk for an overt VTE, and the clinical significance of asymptomatic events, is warranted.

Abstract P230: Risk of Venous Thromboembolism in Acutely Ill Medical Patients and the Influence of Timely Ambulation

Background: Ambulatory status is often considered a criterion for stopping prophylaxis for venous thromboembolism (VTE) in medically ill patients. Methods: A subgroup analysis of the Prophylaxis in Medical Patients with Enoxaparin (MEDENOX) trial was performed according to ambulatory status. Ambulatory status was defined as the ability to attain autonomous walking distance of &gt; 10 meters assessed at visit day 10 ± 4. Incidence of VTE and bleeding was evaluated. Results: The majority of patients (607 of 1084) were ambulatory at visit day 10 ± 4, with a mean time to ambulation of 4.4 days. Thromboprophylaxis was provided for a mean of 7.3 days in the ambulatory subgroup and 7.9 days in the non-ambulatory subgroup. Main results are displayed in the graph. Major bleeding was not significantly different between enoxaparin 40 mg once daily versus placebo in the ambulatory (1 of 212 vs 1 of 190, respectively) or non-ambulatory subgroups (5 of 146 vs 3 of 169). In a multivariate logistic regression model to assess which factors influenced the probability of individual patients becoming ambulatory, ambulatory patients were less likely than non-ambulatory patients to be aged &gt; 75 years (OR 0.57; 95% CI 0.43-0.75; P &lt; 0.0001) and to have a previous history of VTE (OR 0.61; 95% CI 0.38-0.95; P = 0.03). Provision of VTE prophylaxis or placebo did not affect ambulatory status. Conclusions: Despite timely mobilization, medically ill patients who become ambulatory in hospital remain at substantial risk of VTE and have significant VTE risk reduction with enoxaparin 40 mg once daily, as also observed in non-ambulatory patients. Ambulatory status is significantly influenced by baseline characteristics.

Barriers and potential solutions toward optimal prophylaxis against deep vein thrombosis for hospitalized medical patients: A survey of healthcare professionals

Deep vein thrombosis (DVT) prophylaxis remains underused in hospitalized medical patients despite strong recommendations that at-risk patients should receive prophylaxis. To understand this gap between knowledge and practice, we surveyed clinicians' perceptions about the importance of DVT prophylaxis, barriers to guideline implementation, and interventions to optimize prophylaxis. Paper- and electronic mail-based surveys were sent to 1553 internists, nurses, pharmacists, and physiotherapists in Ontario, Canada. Responses were scored on 7-point Likert scales. An important barrier to optimal DVT prophylaxis was 1 with a mean score ≥5, and interventions with high potential success or feasibility were those with mean scores ≥5. DVT prophylaxis was perceived as important by all clinician groups but this did not appear to translate into knowledge about underutilization of current DVT prophylaxis strategies. Physicians and pharmacists recognized the underuse of DVT prophylaxis in medical patients, while nurses and physiotherapists tended to perceive prophylaxis strategies as appropriate. Lack of clear indications and contraindications for prophylaxis and concerns about bleeding risks were perceived as important barriers. Preprinted orders were considered the most potentially successful and feasible way to optimize prophylaxis. A considerable barrier to optimal DVT prophylaxis utilization may be that those healthcare providers best able to conduct a daily assessment of patients' need for prophylaxis underrecognize the problem that prophylaxis is underutilized in this population. Interventions to bridge the gap between knowledge and practice should consider preprinted orders outlining DVT risk factors, and educating front-line care providers prior to implementation of a top-down approach.

Standard or extended-duration prophylaxis in medical patients? A review of the evidence

Acutely ill medical patients are at significant risk of venous thromboembolism (VTE). Thromboprophylaxis can substantially reduce the incidence of VTE, but to be optimally effective must consist of the correct choice of agent, at an appropriate dose, and for sufficient duration. Increasing evidence suggests that VTE risk persists beyond the standard period of prophylaxis. Although there is evidence that extended-duration prophylaxis is beneficial in preventing late VTE complications in high-risk surgical patients, few data exist in medical patients. The recent EXCLAIM study demonstrated that, subsequent to a standard prophylaxis regimen of 10±4days with enoxaparin 40mg once daily, extended-duration prophylaxis (28±4days) with enoxaparin reduced total VTE events compared with placebo: 2.5% versus 4.0%; (absolute risk difference -1.53%; 95.8% confidence interval [CI] -2.54 to -0.52), with parallel increases in major bleeding rates (0.8% vs. 0.3%; absolute risk difference 0.51%; 95% CI 0.12-0.89%). The reduction in total VTE was principally driven by a decrease in symptomatic deep-vein thrombosis (absolute risk difference -0.60%; 95.8% CI -1.00 to -0.19%). Favorable benefit-to-risk ratios were observed in certain high-risk patient groups: level 1 immobility, women, and age>75years. In addition to their underlying medical condition, medical patients often have multiple risk factors, placing them at sustained risk of VTE. Extended-duration prophylaxis might be most relevant in such patients. The development of appropriate risk assessment tools could help identify medical patients at greatest risk of late VTE events who might benefit most from extended-duration prophylaxis.

The Underutilization of Venous Thromboembolism Prophylaxis in Medical Patients

Venous thromboembolism (VTE), long been recognized as a preventable complication of hospitalization, is becoming more widely recognized as a risk for both medical and surgical patients. Recommendations exist for VTE prophylaxis (PPX) in medical patients, but current research shows that the utilization of these guidelines is suboptimal. The rates of VTE PPX are lower than recommended rates, and in those patients receiving PPX, the type, dosage, or duration is not in accordance with recognized recommendations. The recommendations and protocols for medical patients that are currently available should be followed, and as new research is developed and reviewed, current practice should be changed to reflect it. The clinical nurse specialist is in a unique position to assimilate the current recommendations into practice and to enhance patient care by virtue of having multiple spheres of influence, capable of influencing institution policy, patient, family, nurse, and physician education, and direct patient care. The VTE PPX is not overused, but underused, and institutions, physicians, and nurses all need to be cognizant of patient risk for VTE with the need to treat prophylactically and initiate PPX according to the American College of Chest Physicians guidelines.

Does ambulation modify venous thromboembolism risk in acutely ill medical patients?

In the US, ambulatory status is often a criterion for stopping prophylaxis for venous thromboembolism (VTE). In an analysis of the prophylaxis in MEDical patients with ENOXaparin (MEDENOX) trial, ambulatory status was assessed as outcome and patients grouped accordingly for further analysis. Rates of VTE and bleeding were evaluated. Using multivariate logistic regression, the relationships between thromboprophylaxis, VTE risk, and ambulatory status were assessed. Ambulatory status was reached in 607/1,084 patients, in a mean time of 4.4 days. Thromboprophylaxis was provided for 7.3 and 7.7 days in the ambulatory and non-ambulatory groups. Although VTE rates were lower in ambulatory patients, enoxaparin 40 mg once daily significantly reduced the risk of VTE vs. placebo in ambulatory (3.3% vs. 10.6%; relative risk [RR] = 0.31; 95% confidence interval [CI], 0.13-0.78; p=0.008) and non-ambulatory patients (9.0% vs. 19.7%; RR = 0.46; 95% CI, 0.23-0.91; p=0.02). Major bleeding was not significantly different between enoxaparin and placebo in either group. By multivariate regression analysis, VTE risk in ambulatory patients was lower with enoxaparin vs. placebo (odds ratio [OR] = 0.28; 95% CI, 0.11-0.74; p=0.01), but higher in patients with a history of VTE (OR = 3.74; 95% CI, 1.59-8.84; p=0.003) or cancer (OR = 2.12; 95% CI, 1.00-4.48; p=0.049). Despite timely mobilisation, patients who become ambulatory are at VTE risk and experience a significant risk reduction with enoxaparin 40 mg. Therefore, it is essential that ambulatory patients receive recommended thromboprophylaxis.