Recommendations For Venous Thromboembolism Prophylaxis Research Articles

Anticoagulation stewardship: Improving adherence to clinical guidelines and reducing overuse of venous thromboembolism prophylaxis in hospitalized medical patients

Adherence to guideline recommendations for venous thromboembolism prophylaxis (VTE) in hospitalized medical patients is suboptimal despite national policies and institutional interventions. The aim of this quality improvement project was to improve adherence to guidelines and decrease the overuse of VTE prophylaxis in order to reduce the institutional cost for heparins. A multidisciplinary anticoagulation stewardship program (ACSP) using the audit and feedback strategy was implemented on the medicine inpatient units at a teaching hospital in Canada. The primary outcome measure was a comparison, pre and post introduction of the ACSP, of the costs per 6-month period for prophylactic dose enoxaparin and unfractionated heparin on the medicine units. The balancing measures were the 90-day VTE rate and major bleeding rate during the hospitalization. Six months after the implementation of the ACSP, the cost was decreased by >50 % without any observed negative impact on patient safety. This study demonstrates the potential for anticoagulation stewardship programs to optimize the use of VTE prophylaxis and reduce the associated costs and risks.

114 Burn Specific VTE Prophylaxis: Higher Enoxaparin Dose and Anti-Xa Adjustments Is Safe and Potentially Beneficial

Abstract Introduction Burn and trauma patients are at high risk of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolus (PE). VTE prophylaxis guidelines for trauma patients recommends a higher standard dose of enoxaparin and anti-Xa level adjustments in select patients; however, no guidelines specific to burn patients exist. We hypothesize that higher standard doses of enoxaparin and anti-Xa level adjustments will be safe and effective at reducing VTE complications in burn patients. Methods This retrospective review included patients admitted to a regional burn center six months prior to and after the initiation of a VTE prophylaxis quality improvement protocol. The protocol doubled the standard dose of enoxaparin, 40 mg daily to 40 mg twice a day, for all burn patients who were > 50 kg and had creatinine clearance > 60mg/dl. Peak anti-Xa level monitoring was indicated if a high-risk factor (TBSA ≥20%, inhalation injury, burn shock, BMI ≥40) was present. Patients on therapeutic anticoagulation or anti-platelet therapy, had a history of chronic kidney disease, decompensated cirrhosis, coagulation disorder, heparin induced thrombocytopenia (HIT), or were admitted for polytrauma were excluded. Efficacy was evaluated by rates of VTE within 31 days of discharge. Safety was evaluated by bleeding complications, including estimated blood loss (EBL), number of transfusions and gastrointestinal (GI) bleeding events. Differences between groups were compared using a two-sample t-test or Wilcoxon rank-sum test. A p-value of < 0.05 signified statistical significance. Results The pre-protocol group included 217 patients and the post-protocol group included 207 patients. There were no significant differences in age (45 vs 44 years), BMI (27 vs 26.4 kg/m2), TBSA (5.9 vs 5.3%), IHI (4.6 vs 7%), number of procedures (3 vs 3), mortality (4.1 vs 3%), or ICU length of stay (1.9 vs 1.6 days) between groups. No significant difference in EBL (50 vs 25 cc), number of transfusions (3.3 vs 2.4 units), or GI bleeding events (1 vs 1) was noted between groups, and no patient developed thrombocytopenia or HIT. There were 5 patients (2.3%) with a VTE within 31 days of discharge in the pre-protocol group compared to 1 patient (0.4%) in the post-protocol group (p=0.19). There was not enough power to determine statistically significant VTE prevention. Conclusions A lack of VTE prophylaxis recommendations for burn patients leads to variability in protocols among burn centers. These protocols are infrequently studied. This protocol, which doubled the standard dose of enoxaparin and adjusted based on anti-Xa levels for high-risk patients, was safe. Efficacy and applicability to other centers needs further elucidation. Applicability of Research to Practice Enoxaparin 40mg twice a day with anti-Xa level adjustments is safe and a promising strategy to reduce the rates of VTE in the burn population without increasing bleeding complications.

Current trends for venous thromboembolic prophylaxis for hip arthroscopy: a modified Delphi and nominal group technique consensus study

ABSTRACT The overall risk of venous thromboembolism (VTE) after hip arthroscopy (HA) is reported to range from 0.2% to 9.5%, but a clear set of recommendations for VTE prophylaxis in HA patients remains scarce. The aim is to survey high-volume hip arthroscopists about their current trends regarding VTE prophylaxis use. A combination of two consensus group methods was used in this study: nominal group technique (NGT) and modified Delphi. A preliminary questionnaire was prepared, and rounds of discussion were completed between NGT members. The final version of the survey was administered to 35 high-volume hip surgeons. Delegates’ mean volume of annual hip arthroscopic surgery was 109. Approximately 22% of their patients are revision HA procedures. A total of 91.4% of delegates use chemoprophylaxis, 28.6% use sequential compression devices and 91.4% believed that chemoprophylaxis is necessary for more prolonged and complex procedures (strong consensus). Aspirin was the choice for all participants, and the duration was 2–3 weeks (31.4%), 1 month (65.7%) and 2–3 months (2.9%). History of VTE, hypercoagulable status, and malignancy were considered risk factors. No consensus was achieved for the discontinuation of oral contraceptive and smoking preoperatively. However, the optimal length of VTE prophylaxis is unclear. A total of 97.1% of the experts responded that they administer aspirin between 2 and 4 weeks. High-volume arthroscopic surgeons do consider VTE prophylaxis to be important and warranted in the postoperative setting. Aspirin is the mainstay of chemoprophylaxis, although the appropriate duration is unknown.

The Net Benefit of Venous Thromboembolism Prophylaxis in Mild-Risk Thrombophilia and Pregnancy: A Systematic Review and Meta-Analysis

Background: Pregnancy is a known hypercoagulable state. Traditionally, pregnant patients with high risk thrombophilias, which include homozygous Factor V Leiden (FVL), homozygous prothrombin gene variant (PGV), antithrombin deficiency, and double heterozygotes for thrombophilia are treated prophylactically with anticoagulation due to their significantly increased risk of venous thromboembolism (VTE). However, for pregnant patients with mild-risk thrombophilia, which include heterozygous FVL and heterozygous PGV, VTE risk is lower and VTE prophylaxis is not typically recommended and decision to use anticoagulation is typically left to the physician's discretion based on each patient's individual risk factors. To date, there is not a systematic review or meta-analysis which reviews recommendations for VTE prophylaxis in the antenatal and postnatal periods in patients who are pregnant with known mild thrombophilia. The aim of this meta-analysis is to assess the association of thromboprophylaxis in prevention of obstetric complications and pregnancy-related VTE in women with known mild-risk inherited thrombophilia: heterozygous FVL or PGV, Protein C and S deficiencies. Methods: The Medline, Embase, Lilacs, and the Cochrane Central Register of Controlled Trials (Central) was searched from inception to October 7, 2022. Identified studies were then screened by reviewers for inclusion. Inclusion criteria considered pregnant patients (antenatal) up until 6 weeks post-delivery or miscarriage (puerperium) with a known mild risk inherited thrombophilia (heterozygous FVL or PGV, Protein C or Protein S deficiency), receipt of thromboprophylaxis in either the antepartum, puerperium period, or both (prophylactic and intermediate dosing of LMWH or UFH, low-dose aspirin, or a combination of these). Control group was defined as pregnant patients with known mild thrombophilia who did not receive thromboprophylaxis in the antenatal and puerperium periods. Primary outcome was defined as VTE-related mortality and all-cause mortality, and secondary outcome was defined as adverse effects (including VTE, maternal and fetal complications, bleeding events). Statistical analysis was performed using OpenMeta[Analyst]. Results: In total 1,121 publications were identified through the database search, and one additional publication was identified through manual search. After screening processes by two separate reviewers, seven full text studies were determined to meet inclusion criteria and were used for data extraction and analysis. (Figure 1) Across the studies included, no events of VTE-related mortality or all-cause mortality were reported. Three studies, with a population of 1265 women, were amenable for meta-analysis of VTE and adverse events. Results showed an association with thromboprophylaxis and decreased risk of VTE (OR 0.210, 95% CI 0.082-0.538, p-value 0.001) (Figure 2). Adverse outcomes of pregnancy loss, small for gestational age (SGA), and pre-eclampsia or eclampsia were not statistically different between pregnant women who received thromboprophylaxis versus those who did not. Discussion: Results of this meta-analysis show an association between thromboprophylaxis and decreased risk of VTE events when compared to no thromboprophylaxis in pregnant women with mild thrombophilia. Adverse outcomes did not appear to be different in those pregnant women who received thromboprophylaxis. Limitations of this study include heterogeneity of different thromboprophylaxis modalities among study designs, limited data on mortality and other adverse effects including bleeding and fetal complications. Although results of this meta-analysis were able to detect a decreased risk of VTE with exposure to thromboprophylaxis, further prospective studies are needed to establish the safety of thromboprophylaxis in that population.

Venous thromboembolism in orthopedic surgery: Global guidelines.

Venous thromboembolism (VTE) is a severe complication that can occur after major orthopedic procedures. As VTE-related morbidity and mortality are a significant concern for both medical professionals and patients, and preventative measures are typically employed. Multiple organizations, including the American College of Chest Physicians (ACCP) and the American Academy of Orthopedic Surgeons (AAOS), have developed guidelines for VTE prophylaxis specifically in patients undergoing joint replacement procedures. However, recently, the International Consensus Meeting (ICM) was convened, which brought together over 600 experts from 68 countries and 135 international societies. These experts, spanning a range of medical disciplines including orthopedic surgery, anesthesia, cardiology, hematology, vascular, and internal medicine, conducted a comprehensive review of the literature using a strict Delphi process to generate practical recommendations for VTE prophylaxis across all types of orthopedic procedures. This review article summarizes some of the recommendations of the ICM. Level of Evidence: Level V, Expert opinion.

Risk Assessment Model for Postpartum Venous Thromboembolism Prevention in Patients with Systemic Lupus Erythematosus.

This article assesses the application of the Royal College of Obstetricians and Gynaecologists (RCOG) venous thromboembolism (VTE) risk model on a cohort of postpartum patients with a history of systemic lupus erythematosus (SLE). This is a secondary analysis of an ongoing patient registry of women with SLE from 2016 to 2022. There were 49 SLE patients with 55 pregnancies using the Definitions of Remission in SLE (DORIS) criteria to determine SLE disease activity. RCOG risk assessment model scoring was calculated for each patient prior to and after delivery. The primary outcome was the qualification of "active SLE" by standard rheumatologic criteria and assessment of recommendations for VTE prophylaxis based on RCOG VTE risk assessment scoring. Data were analyzed using Fisher's exact test, chi-square test, and Mann-Whitney U test with significance defined as p < 0.05. In the study cohort, 34 pregnancies (61.8%) were in DORIS remission at delivery. Twenty-one pregnancies (38.2%) were not and scored 3 points on the RCOG VTE risk model. Of these pregnancies, only 19% (n = 4) were recommended for VTE prophylaxis by the obstetrical provider despite RCOG score ≥3. Only 35.7% (n = 5) of pregnancies in DORIS remission, but with 3 points for non-SLE-related VTE risk factors (n = 14), were recommended for VTE prophylaxis. Of the 20 pregnancies in remission with an RCOG score < 3 after assessing all risk factors, 15% (n = 3) were nevertheless recommended for VTE prophylaxis. No patients had a postpartum VTE regardless of therapy. These data reveal a need to improve upon providing postpartum VTE prophylaxis to SLE patients not in remission while also recognizing a diagnosis of SLE alone should not equate with active disease. Moreover, SLE patients in remission may still warrant VTE prophylaxis if other non-SLE-related risk factors are present. · Those with SLE are at increased risk for VTE postpartum.. · VTE prophylaxis should be instituted when clinically appropriate.. · Caution should be exercised in broadly assigning disease activity for SLE diagnosis only.. · This study supports VTE prophylaxis use in postpartum patients with SLE..

Risk Assessment Model for Postpartum Venous Thromboembolism Prevention in Patients with Systemic Lupus Erythematosus

Background Patients with Systemic Lupus Erythematosus (SLE) may be at increased risk for developing a venous thromboembolism (VTE), particularly in the postpartum period. The Royal College of Obstetricians and Gynaecologists (RCOG) guideline for postpartum VTE prophylaxis is often used to triage which patients should get VTE prophylaxis. In this RCOG guideline, a score ≥ 3 drives a formal recommendation for postpartum anticoagulation. RCOG is unique in its inclusion of “active SLE” as an actionable VTE risk factor (adding 3 points). We sought to determine if a cohort of postpartum patients with a known history of SLE a) qualify as having “active” SLE by standard rheumatologic criteria b) have other risk factors for VTE c) received the recommended prophylaxis based on RCOG VTE risk assessment scoring and d) had a postpartum VTE. Objective To assess the application of the RCOG venous thromboembolism (VTE) risk model on a cohort of postpartum patients with a history of Systemic Lupus Erythematosus (SLE). Study Design This is a secondary analysis of an ongoing patient registry of women with SLE from 2016-2022. There were 49 SLE patients with 55 pregnancies using Definitions of Remission in SLE (DORIS) criteria to determine SLE disease activity. RCOG risk assessment model scoring was calculated for each patient prior to and after delivery. The primary outcome was the qualification of “active SLE” by standard rheumatologic criteria and assessment of recommendations for VTE prophylaxis based on RCOG VTE risk assessment scoring. Data were analyzed using Fisher’s Exact test, chi-square test, and Mann-Whitney U test with significance defined as p&lt;0.05. Results In the study cohort, 34 pregnancies (61.8%) were in DORIS remission at delivery. Twenty-one pregnancies (38.2%) were not and scored 3 points on the RCOG VTE risk model. Of these pregnancies, only 19% (n=4) were recommended for VTE prophylaxis by the obstetrical provider despite RCOG score ≥ 3. Only 35.7% (n=5) of pregnancies in DORIS remission, but with 3 points for non-SLE related VTE risk factors (n=14), were recommended for VTE prophylaxis. Of the 20 pregnancies in remission with an RCOG score &lt; 3 after assessing all risk factors, 15% (n=3) were nevertheless recommended for VTE prophylaxis. No patients had a postpartum VTE regardless of therapy. Conclusion These data reveal a need to improve upon providing postpartum VTE prophylaxis to SLE patients not in remission while also recognizing a diagnosis of SLE alone should not equate with active disease. Moreover, SLE patients in remission may still warrant VTE prophylaxis if other non-SLE-related risk factors are present.

Initiative to reduce inappropriate venous thromboembolism prophylaxis in an 11-hospital safety net system: An electronic health records-based approach.

While pharmacologic prophylaxis has benefits for venous thromboembolism (VTE) prevention in high-risk patients, unnecessary use carries potential harm, including bleeding, heparin-induced thrombocytopenia, and patient discomfort, and should be avoided in low-risk patients. While many quality improvement initiatives aim to reduce underuse, successful models on reducing overuse are sparse in the literature. We aimed to create a quality improvement initiative to reduce overuse of pharmacologic VTE prophylaxis. A quality improvement initiative was implemented across 11 safety net hospitals in New York City. The first electronic health record (EHR) intervention consisted of a VTE order panel that facilitated risk assessment and recommended VTE prophylaxis for high-risk patients only. The second EHR intervention used a best practice advisory that alerted clinicians when prophylaxis was ordered for a patient previously deemed "low risk." Prescribing rates were compared through a three-segment interrupted time series linear regression design. Compared to the preintervention period, the first intervention did not change the rate of total pharmacologic prophylaxis immediately after implementation (1.7% relative change, p = .38) or over time (slope difference of 0.20 orders per 1000 patient days, p = .08). Compared to the first intervention period, the second intervention led to an immediate 4.5% reduction in total pharmacologic prophylaxis (p = .04) but increased thereafter (slope difference of 0.24, p = .03) such that weekly rates at the end of the study were similar to rates prior to the second intervention.

Applying the 2005 Caprini Score to Plastic Surgery Patients: A Quality Improvement Project.

The Caprini score is a validated scale that calculates a patient's 30-day venous thromboembolism (VTE) risk based on their comorbidities. The American Society of Plastic Surgeons published VTE prophylaxis recommendations in 2011 based on the Caprini score, but these recommendations are vague and up to physician interpretation. The purpose of this study is to evaluate postoperative outcomes after the application of strict guidelines using the Caprini score with specific VTE chemoprophylaxis benchmarks on plastic surgery patients. A retrospective cohort analysis was performed on all plastic surgery patients who underwent surgery between July 2019 and July 2021. Patients between July 2019 and June 2020 were not subjected to any specific VTE prophylaxis protocol, while patients from July 2020 to July 2021 were subjected to the newly created VTE prophylaxis protocol. Every patient received a calculated Caprini score at their preoperative history and physical. The primary outcomes measured include hematoma, deep vein thrombosis (DVT) and pulmonary embolism (PE). Four hundred forty-one patients with 541 procedures were included in this study, with 275 patients in the "before" group and 166 patients in the "after" group. A total of 78.6% of patients received chemoprophylaxis in the "before" group compared with 20% in the "after" group. There was no significant difference in postoperative complications between the two groups including PE or DVT (P = 0.2684 and 0.2696, respectively), with a trend toward hematoma formation in the "before" group (P = 0.1358). After the application of evidence-based VTE guidelines, the patients stayed fewer days in the hospital (0.4 vs 0.7 days, P = 0.0085) and were less likely to be readmitted (2.4% vs 6.5%, P = 0.0333). The average cost per patient in the "before" group was $9.11 with a total cost of $3022.90. The average cost per patient in the "after" group was $4.23 with a total cost of $867.94 (P = 0.032). Our strict application of the Caprini score significantly and safely limited the number of patients receiving postoperative VTE chemoprophylaxis and showed no significant difference in postoperative hematoma, DVT, or PE.

The Pattern of Heparin Dosing as Venous Thromboembolism Prophylaxis in Adult Underweight Patients Admitted to Critical Care Units at a Tertiary Hospital.

Venous thromboembolism (VTE) is one of thecauses of hospital-related deaths in critically ill patients. Guidelines recommended VTE prophylaxis with standardized, fixed doses for most patients. The underweight population has limited data to guide the appropriate drug and dosing regimen. The aim of this study was to describe the pattern of VTE prophylaxis dose regimens for underweighted critically ill adult patients and the prevalence of associated VTE and bleeding. This study is a retrospective cohort study, conducted at the King Abdulaziz Medical City, Riyadh, Saudi Arabia. It included all critical patients admitted to the intensive care units (ICUs) and were above 14 years old with weight less than 50 kg or body mass index (BMI) of 18.5 kg/m2 or less, and were on heparin as VTE prophylaxis for more than 72 h from January 2016 until January 2020. After screening 270 patients, only 40 patients were included in this study according to our inclusion and exclusion criteria. Only six patients (15%) received VTE prophylaxis as an adjusted dose of heparin 2500 U Q12, while the rest of the patients were taking standard dosing of heparin; 5000 U Q12 was given to 21 (52.50%) patients, and 5000 U Q8 was given to 13 (32.50%) patients. None of the adjusted doses developed any complications such as VTE or bleeding. There was no significant difference compared with the standard dose group. In this study, we described the pattern of heparin doses as VTE prophylaxis in underweight patients. We also compared the standard dosing and adjusted dosage of VTE prophylaxis on underweight patients and any complications. There was no significant difference in the complications outcome or benefits between the two groups.

Thromboprophylaxis in Urological and Andrological Surgery (Review article)

Last decades urologist started to performed big amount of complicated oncological operation with substantial risk of both venous thromboembolism (VTE) and bleeding. Prophylaxis of VTE remains a vital problem, as it is potentially fatal and is associated with significant morbidity. Prophylaxis of this complication is not clearly defined and is mainly based on information from other surgical specialties (like orthopedic or general surgery). Scientific publications dedicated VTE prophylaxis in field of urology were reported only in the last decade. Most studies showed that pharmacological prophylaxis decreases the relative risk of VTE in surgical patients by approximately 50%, but with an increase in the relative risk of postoperative major bleeding of 50%. Main models for evaluation of different VTE risk factors were analyzed. The most important risk factors for VTE are age of 75 or more, body mass index 35 or more, prior VTE or VTE in 1st degree relative. As for urological procedure, deep venous thrombosis rates of 0.2–7.8% and pulmonary embolism of 0.2–7% have been reported. It was shown that recommendations for VTE prophylaxis varies in different guidelines and their summary for most popular operations were described. Generally, most recommendations state that low-risk procedures need no prophylaxis or solely mechanical prophylaxis. Moderate-risk categories can either have mechanical or pharmacological prophylaxis. The high-risk category should have both mechanical and pharmacological prophylaxis, and extended prophylaxis should be considered. Despite massive evidences about risk of VTE among different types of surgical patients, real clinical practice doesn’t show the strict adherence to VTE prophylaxis recommendations.

Qualitative analysis of randomized controlled trials informing recommendations for venous thromboembolism prophylaxis after distal lower extremity injuries.

Purpose:The purpose of this study is to assess the quality of evidence to stratify recommendations for chemoprophylaxis following distal lower extremity trauma.Methods:Literature review identified primary studies investigating venous thromboembolism (VTE) chemoprophylaxis following traumatic injury distal to the knee. Inclusion criteria were randomized controlled trials in adult patients treated with and without operative intervention. Each primary study was assessed by the Consolidated Standards of Reporting Trials 2010 checklist and Modified Coleman methodology score.Results:Literature review resulted in 462 studies, of which 9 met inclusion and exclusion criteria. All studies included low molecular weight heparin as a treatment group with 2 (22%) also including a treatment group with a direct factor Xa inhibitor. Five studies (56%) used placebo as a control group. The mean Modified Coleman Methodology score was 63% (range 51%–72%), a categorical rating of Fair. The mean Consolidated Standards of Reporting Trials score was 78% (range 56%–97%). Most studies (89%) screened all asymptomatic subjects for deep venous thrombosis. Statistical significance in VTE incidence among prophylactic treatment groups was not achieved in 78%.Conclusions:Development of consensus for VTE prophylaxis recommendations following traumatic injury distal to the knee is complicated by heterogenous study populations, low incidence of VTE in study populations, and inconsistent definitions of clinically important VTE. Low molecular weight heparin is not consistently superior for preventing VTE. Chemoprophylaxis should be considered on an individual basis in the presence of additional risk factors, although an externally validated, evidence-based risk assessment tool does not currently exist.Level of Evidence: IV, therapeutic

Optimizing Thromboembolism Prophylaxis for the Contemporary Age of Multiple Myeloma.

Venous thromboembolism (VTE) is a major complication in all patients with cancer. Compared with the general population, patients with multiple myeloma (MM) have a 9-fold increase in VTE risk, likely because of their malignancy, its treatments, and other additional patient-related factors. In MM, thromboembolism events tend to occur within 6 months of treatment initiation, regardless of treatment regimen; however, the use of immunomodulatory agents such as thalidomide or lenalidomide, especially in combination with dexamethasone or multiagent chemotherapy, is known to create a significant risk for VTE. Currently, official recommendations for VTE prophylaxis in MM outlined in various national guidelines or multidisciplinary society panels are based on expert opinion, because data from randomized controlled trials are scarce. Large studies which have mainly focused on the efficacy of thromboprophylaxis in patients with cancer at higher risk for VTE either had a very low representation of patients with MM, or excluded them all together, limiting our ability to draw evidence-based conclusions on how to effectively protect MM population from VTE. In this brief perspective, we highlight some of the greatest challenges that have hampered the field concerning the availability of high-quality clinical trial data for the formulation of best VTE prophylaxis strategies in patients with newly diagnosed MM, as well as the rationale for the latest updates in the NCCN Guidelines on this topic.

Incidence, Clinical Profile and Outcome of Patients with Deep Vein Thrombosis and Pulmonary Embolism at a Community Hospital

ObjectiveTo determine incidence of venous thromboembolism (VTE) and to describe risk factors and demographics at a community hospital setting.MethodsProspective study design, recruited 33 patients at Orange Park Medical Center (OPMC). Study was conducted for a period of two months from Feb 2017 to March 2017.All patients aged 18 years and above with an objectively verified diagnosis of DVT, PE or both were included in the study.Baseline demographic data were retrieved from medical records and descriptive analysis was performed with R.Results:During the study period, the incidence rate of VTE diagnoses was 5.9 per 1000 admits [95% confidence interval (CI): 4- 8.2]. Mean age of the patients with VTE event was 51 years, majority were females (51.5%) and Caucasians (69.6%). The average length of stay in the hospital was 3.42 days.Incidence rate for DVT was 1.3 per 1000 admits [95% CI: 1.3- 4.1] and that for PE was 3.7 per 1000 admits [95% CI: 2.3- 5.7]. DVT's were more common among males (57.1%) compared to females (42.8%), whereas PE's were more common in females (66.66%) compared to males (33.33%).Majority of VTE were provoked episodes, accounting for nearly 64% of all causes. Remaining 36% of VTE events were unprovoked due to hypercoagulable states (21%) and a family history of VTE (15%). Among the provoked events, most common causes were malignancy (21%) and recent surgeries (21%) (Figure 1).Among the patients whose risk factor for VTE was recent surgery, majority of them had orthopedic surgeries (57.1%) and received low molecular weight heparins (LMWHs) as prophylaxis for an average duration of two weeks post- surgery.Our results also showed that, 51.5% of patients diagnosed with VTE had at least 1 risk factor for VTE and 48.4% had 2 or more risk factors.ConclusionThis study provides an estimate of incidence of VTE events in adults at a community hospital setting. A sample size of 5590 hospitalized adult patients were analyzed, of which 33 patients were diagnosed with VTE. There have been very few studies reporting the simultaneous effects of multilevel factors such as demographic and preexisting comorbid conditions on the incidence of VTE. When compared to a previous study on VTE in hospitalized patients by Tsai J et al 1, we found a slightly increased incidence rate of 5.9 VTE's per 1000 admits. The difference in the incidence rate could be due to differences in clinical practice of VTE prophylaxis among clinicians, patient's attitudes towards compliance and adherence to therapies. In regards to the risk factors, our study results were consistent with existing evidence that there is a greater risk for VTE among those patients with malignancies and those who have had recent surgeries 2.Patients undergoing major orthopedic surgery are at particularly high risk for VTE. The current pharmacological recommendations for prophylaxis of VTE are LMWHs, fondaparinux and vitamin K antagonists. The results of several studies support extended prophylaxis for 4 weeks in patients undergoing high risk orthopedic surgeries and surgery for cancer. The optimal duration of VTE prophylaxis in other types of surgery needs further evaluation 3.In summary, the results from this study have several important clinical and public health implications. First, physicians need to be informed of various risk factors for VTE, and to identify those who will benefit from VTE prophylaxis. Second, to increase the awareness of VTE among patients and thereby contribute to improved adherence to prescribed therapies.

Venous Thromboembolism Prevention in the Ambulatory Cancer Clinic (VTE-PACC): a Systems-Based, Personalized, Multidisciplinary Program to Increase Venous Thromboembolism (VTE) Risk Assessment, Education and Anticoagulant Prophylaxis in Cancer Outpatients Initiating Therapy

Introduction : Anticoagulant prophylaxis reduces VTE rates by ~50% in selected oncology patients. Among cancer patients starting chemotherapy, 2014 ASCO Guidelines recommend VTE risk assessment, VTE education, and administration of pharmacologic prophylaxis in selected patients. While validated VTE risk stratification tools are available, <10% of oncologists use a risk assessment tool in practice. Further, evidence-based and practical guidance for how to implement VTE prevention guidelines in cancer outpatients is lacking.Hypothesis : Implementation of a systems-based multidisciplinary program that utilizes the electronic health record (EHR) and offers personalized VTE prophylaxis recommendations by consulting hematologists would increase VTE risk assessment, increase VTE education rates, and increase the rate of VTE prophylaxis in high risk patients initiating outpatient chemotherapy.Methods: At a tertiary university cancer center, based on a quality improvement framework with an iterative design to refine the intervention over time, VTE-PACC is a multidisciplinary thrombo-oncology program developed and implemented by nurses, oncologists, pharmacists and hematologists. We identified high risk patients, provided standardized VTE education, and tailored prophylaxis for adult cancer outpatients initiating chemotherapy. Patients receiving hormonal therapy or with brain cancer were not included in the program. An assessment of VTE risk using the Khorana and Protecht scores via the EHR was built into clinical process flow and all patients were provided education on VTE symptoms and risk reduction. Patients with a high predicted VTE risk during treatment (defined as ≥3 points on the Khorana or Protecht score) were offered a hematology consultation to consider VTE prophylaxis. Results of the consultation including individualized drug and dosing recommendations were communicated to the treating oncologist.Results : Between October 1, 2015 and July 1, 2017 (comprising a 6 month implementation phase and subsequent 15 months post implementation), 850 patients were evaluated. VTE risk assessment and education rates increased from less than 5% to 84.3% (range 65.8- 97.6% per month) during the implementation phase. Improvement in EHR documentation processes and clinical work flow resulted in a further increase to 94.9% over the subsequent 15 months. In the post-implementation phase, 153 patients (23.7%) were identified as high risk of VTE based on the Khorana or Protecht scores and offered referral to hematology. The largest patient derived factor for referral acceptance was consultative visits coincident with receiving therapy or an oncology visit. Of these high risk patients, 86% received prophylactic anticoagulation therapy (49% DOAC (direct oral anticoagulant), 32% low molecular weight heparin, 17% unfractionated heparin and 2% warfarin).Conclusion: The VTE-PACC intervention used a multidisciplinary EHR based approach to improve VTE risk assessment and education rates in cancer outpatients initiating therapy. The great majority of high risk patients also received prophylactic anticoagulation. As large trials on the benefits and risks of pharmacologic prophylaxis are completed, methods applied here may readily translate these findings into practice. DisclosuresNo relevant conflicts of interest to declare.

Impact of a Clinical Decision-Support Tool on Venous Thromboembolism Prophylaxis in Acutely Ill Medical Patients.

Background: Adherence to guideline-based venous thromboembolism (VTE) prophylaxis recommendations is often inadequate. Effective improvement strategies are needed. Objective: The purpose of this quality improvement initiative was to increase use of the facility's preferred pharmacologic VTE prophylaxis, reduce unnecessary VTE prophylaxis use, and reduce use of pharmacologic VTE prophylaxis in high bleeding risk patients, in accordance with guideline-based recommendations. Methods: Clinical pharmacists spearheaded the development and implementation of a clinical decision-support tool (CDST) integrated within a Veterans Health Administration electronic health record (EHR). The CDST focused on VTE prophylaxis in acutely ill medical patients and guided prescribers to guideline-based recommendations. Following review and approval, the CDST underwent activation in the EHR. A subsequent intervention occurred, year 2 post-intervention, which embedded this CDST into the EHR admission process and admission menus. A drug message was added in the EHR to alert prescribers that low-molecular-weight heparin was the preferred agent. Measures were evaluated pre-intervention, year 1 post-intervention, and year 2 post-intervention. Results: After intervention, there were statistically significant increases in the proportion of patients receiving the facility's preferred pharmacologic VTE prophylaxis agent, enoxaparin, and a statistically significant decrease in the proportion of unwarranted VTE prophylaxis. The proportion of inappropriate pharmacologic VTE prophylaxis in high bleeding risk patients decreased, but this result did not reach statistical significance. Conclusion: The improvements observed suggest the beneficial role of CDSTs integrated into the EHR to increase adherence to guideline-based VTE prophylaxis recommendations.

Extended Venous Thromboembolism Prophylaxis in Medically Ill Patients: An NATF Anticoagulation Action Initiative

Hospitalized patients with acute medical illnesses are at risk for venous thromboembolism (VTE) during and after a hospital stay. Risk factors include physical immobilization and underlying pathophysiologic processes that activate the coagulation pathway and are still present after discharge. Strategies for optimal pharmacologic VTE thromboprophylaxis are evolving, and recommendations for VTE prophylaxis can be further refined to protect high-risk patients after hospital discharge.An early study of extended VTE prophylaxis with a parenteral agent in medically ill patients yielded inconclusive results with regard to efficacy and bleeding. In the Acute Medically Ill VTE Prevention with Extended Duration Betrixaban (APEX) trial, extended use of betrixaban halved symptomatic VTE, decreased hospital readmission, and reduced stroke and major adverse cardiovascular events compared with standard enoxaparin prophylaxis. Based on findings from APEX, the Food and Drug Administration approved betrixaban in 2017 for extended VTE prophylaxis in acute medically ill patients. In the Reducing Post-Discharge Venous Thrombo-Embolism Risk (MARINER) study, extended use of rivaroxaban halved symptomatic VTE in high-risk medical patients compared with placebo. In 2019, rivaroxaban was approved for extended thromboprophylaxis in high-risk medical patients, thus making available a new strategy for in-hospital and post-discharge VTE prevention.To address the critical unmet need for VTE prophylaxis in medically ill patients at the time of hospital discharge, the North American Thrombosis Forum (NATF) is launching the Anticoagulation Action Initiative, a comprehensive consensus document that provides practical guidance and straightforward, patient-centered recommendations for VTE prevention during hospitalization and after discharge.

Successful Model for Guideline Implementation to Prevent Cancer-Associated Thrombosis: Venous Thromboembolism Prevention in the Ambulatory Cancer Clinic.

PURPOSE:Guidelines recommend venous thromboembolism (VTE) risk assessment in outpatients with cancer and pharmacologic thromboprophylaxis in selected patients at high risk for VTE. Although validated risk stratification tools are available, < 10% of oncologists use a risk assessment tool, and rates of VTE prophylaxis in high-risk patients are low in practice. We hypothesized that implementation of a systems-based program that uses the electronic health record (EHR) and offers personalized VTE prophylaxis recommendations would increase VTE risk assessment rates in patients initiating outpatient chemotherapy.PATIENTS AND METHODS:Venous Thromboembolism Prevention in the Ambulatory Cancer Clinic (VTEPACC) was a multidisciplinary program implemented by nurses, oncologists, pharmacists, hematologists, advanced practice providers, and quality partners. We prospectively identified high-risk patients using the Khorana and Protecht scores (≥ 3 points) via an EHR-based risk assessment tool. Patients with a predicted high risk of VTE during treatment were offered a hematology consultation to consider VTE prophylaxis. Results of the consultation were communicated to the treating oncologist, and clinical outcomes were tracked.RESULTS:A total of 918 outpatients with cancer initiating cancer-directed therapy were evaluated. VTE monthly education rates increased from < 5% before VTEPACC to 81.6% (standard deviation [SD], 11.9; range, 63.6%-97.7%) during the implementation phase and 94.7% (SD, 4.9; range, 82.1%-100%) for the full 2-year postimplementation phase. In the postimplementation phase, 213 patients (23.2%) were identified as being at high risk for developing a VTE. Referrals to hematology were offered to 151 patients (71%), with 141 patients (93%) being assessed and 93.8% receiving VTE prophylaxis.CONCLUSION:VTEPACC is a successful model for guideline implementation to provide VTE risk assessment and prophylaxis to prevent cancer-associated thrombosis in outpatients. Methods applied can readily translate into practice and overcome the current implementation gaps between guidelines and clinical practice.

Thromboprophylaxis during the Pregnancy-Puerperal Cycle - Literature Review.

To identify current strategies and recommendations for venous thromboembolism prophylaxis associated with the pregnancy-puerperal cycle, a condition of high morbidity and mortality among women. The literature search was performed between May and October 2019, using the PubMed database, including papers published in Portuguese, English and Spanish. The terms thromboembolism (Mesh) AND pregnancy (Mesh) OR postpartum (Mesh) were used as descriptors, including randomized controlled trials, meta-analyses, systematic reviews and guidelines published from 2009 to 2019, presenting strategies for prevention of thromboembolism during pregnancy and the postpartum. Eight articles met the inclusion criteria. Many studies evaluated were excluded because they did not address prevention strategies. We compiled the recommendations from the American Society of Hematologists, the American College of Obstetricians and Gynecologists, the Royal College of Obstetricians and Gynecologists, the Society of Obstetricians and Gynaecologists of Canada, the American College of Chest Physicians and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. There are some gaps in the research, and clinical studies with appropriate methodology are needed to support decisions made regarding the risk of thromboembolism in the perigestational period. Thus, the attention of the professionals involved in the care of pregnant and postpartum women is crucial, as it is a condition associated with high morbidity and mortality.

Recommendations for VTE Prophylaxis in Medically Ill Patients.

Venous thromboembolism (VTE) remains highly prevalent in medically ill patients, and often leads to increased mortality and cost burden during hospitalization and post-discharge. Nearly half of all VTEs occur during or after hospitalization, with pulmonary embolism accounting for 10% of inpatient mortality. Appropriate prophylaxis in high-risk medically ill patients has been shown to reduce risk of VTE and related mortality. Despite current evidence-based guidelines, VTE prophylaxis has been under-used. This owes greatly to ambiguity and concerns related to appropriate patient and prophylactic agent selection, and duration of prophylaxis. Because many acutely ill medical patients have multiple comorbidities, the risk of major bleeding must be considered when choosing to implement pharmacological VTE prophylaxis. Multiple risk assessment models have been developed and validated to help estimate VTE and bleeding risks in this population. While studies have shown that the risk for VTE often extends far beyond hospital discharge, there is no evidence to support extending prophylaxis after hospital discharge. The appropriate selection of VTE prophylaxis requires consideration for cost, availability, patient preference, compliance, and underlying comorbidities. Our paper reviews the current evidence and reasoning for appropriate selection of VTE prophylaxis in acutely medical ill patients, and highlights our own approach and recommendations.