Guidelines For Prevention Of Venous Thromboembolism Research Articles

Increasing venous thromboembolism risk assessment through a whole hospital-based intervention: a pre-post service evaluation to demonstrate quality improvement.

Venous thromboembolism (VTE) is a primary cause of morbidity and mortality in hospitalized patients. VTE risk assessment is a crucial part of the VTE prevention guideline. However, VTE risk assessment was not consistently undertaken for admitted patients. The aim of this study was to identify whether a quality improvement project implemented to change documentation of VTE risk assessment for hospitalized patients impacted patient safety by decreasing the rate of VTE incidences. The study was set in a 600+ bed acute hospital that provides medical and surgical services for adult patients during the period October 2018-September 2020. The hospital adopted the American College of Chest Physicians (ACCP) 9th edition VTE prevention guidelines and followed the Modified Caprini risk assessment tool. Following the FOCUS-Plan-Do-Check-Act (FOCUS PDCA) improvement methodology, the improvement team implemented multicomponent interventions over a 3-month period, including conducting educational sessions, sharing VTE documentation compliance results, giving reminders during rounds, assigning a VTE liaison physician within each clinical specialty, and updating and communicating the hospital adopted VTE guidelines. A total of 17 612 patients were included, respectively, 8971 in pre-intervention and 8641 post-intervention period. Documentation of VTE risk assessment upon admission increased significantly in the post quality improvement intervention period (60% vs. 42%, relative increase of 30%, χ2 = 1.43, P < 0.001). The run chart trend analysis demonstrated significant improvement shift and improvement trend after quality improvement project implementation, and it was sustained for 15 months. There was no impact on patient safety with a slight not statistically significant decrease in the VTE incidences rate post intervention period (0.4% vs. 0.5%, relative decrease of 1%, χ2 = 0.82, P < 0.397). The quality improvement project intervention significantly increased the percentage of patients assessed for VTE risk in a hospital setting.

Projected impact of guidelines on incidence of venous thromboembolism after cesarean delivery in the United States

BackgroundThere is large variation in recommended for postcesarean delivery venous thromboembolism (VTE) prophylaxis among commonly used guidelines. ObjectivesThe aim of the study is to estimate implications of adoption of VTE prevention guidelines for rates of receipt of VTE prophylactic therapy and VTE following cesarean delivery (CD). MethodsWe used administrative data from the 2015-2019 Nationalwide Readmissions Database to identify cesarean deliveries and rates of VTE stratified by risk factors, leading to different prophylactic strategies based on several national guidelines. We used input parameters from the literature to construct a hybrid decision tree/Markov model to project the implications of guideline adoption on VTE rates for the first 6 weeks following delivery. ResultsAdoption of either the 2011 American College of Obstetricians and Gynecologists or the 2018 American Society for Hematology guidelines would avert a relatively small proportion (5%) of VTE cases, albeit with little low-molecular-weight heparin (LMWH) use (87-115 doses per 1000 CD patients). The 2012 American College of Chest Physicians guidelines were predicted to be more effective at averting VTE (21.2% reduction) with more LMWH usage (570 doses per 1000 deliveries). The 2015 Royal College of Obstetricians and Gynaecologists guidelines and universal use of 6 weeks of LMWH would avert an even larger proportion of cases (37.4% and 57.6%, respectively), at the cost of much higher rates of LMWH utilization (7233 doses per 1000 patients and 38 648 doses per 1000 patients). ConclusionsAdoption of different guidelines would have notably varying implications for clinical practice and potential for alteration of the national rate of VTE following CD.

Venous thromboembolism prophylaxis following colorectal surgery: a survey of American Society of Colon and Rectal Surgery (ASCRS) member surgeons.

Postoperative venous thromboembolism (VTE) is associated with significant morbidity. Evidence from other surgical specialties demonstrate inadequate use of extended VTE prophylaxis following cancer surgery. While guidelines recommend extended VTE prophylaxis for patients undergoing surgery for colorectal cancer (CRC), it is unknown to what extent colon and rectal surgeons adhere to these recommendations. An 18-question online survey was distributed to all surgeon members of the American Society of Colon and Rectal Surgeons (ASCRS). The survey was designed to capture knowledge, attitudes, and practices regarding ASCRS VTE prevention guidelines. Questions were also designed to elucidate barriers to adopting these guidelines. The survey was distributed to 2,316 ASCRS-member surgeons and there were 201 complete responses (8.7% response rate). Most respondents (136/201, 68%) reported that they were familiar with ASCRS VTE prevention guidelines and used them to guide their practice. Extended VTE prophylaxis was reported to be routinely prescribed by the majority of surgeons following CRC resection (109/201, 54%), with an additional 27% reporting selective prescribing (55/201). The most frequently reported reasons for not prescribing extended VTE chemoprophylaxis following CRC resection included patient compliance and insurance/copay issues. Most ASCRS-member surgeon respondents reported that they are familiar with ASCRS VTE prevention guidelines, though only 54% surgeons reported routinely prescribing extended VTE prophylaxis following CRC surgery. Patient compliance and insurance issues were identified as the most common barriers. Targeted interventions at the surgeon, patient, and payer level are required to increase the use of extended VTE prophylaxis following CRC resection.

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.

Safety of Erector Spinae Plane Blocks in Patients With Chest Wall Trauma on Venous Thromboembolism Prophylaxis

BackgroundCurrent guidelines for severe rib fractures recommend neuraxial blockade in addition to multimodal pain therapies. While the guidelines for venous thromboembolism prevention recommend chemoprophylaxis, these medications must be held for neuraxial blockade placement. Erector spinae plane block (ESPB) is a newly described block for thoracic pain control. Advantages include its quick learning curve and potential for less bleeding complications. We describe the use of ESPB for rib fractures in patients on chemoprophylaxis. We hypothesize that ESPB can be performed in this patient population without holding chemoprophylaxis. Materials and methodsThis was a retrospective observational cohort study of a level 1 trauma center from 9/2016 to 12/2018. All patients with trauma with rib fractures undergoing neuraxial blockade or ESPB were included. Demographics, chemoprophylaxis and anticoagulation regimens, outcomes, and complications were collected. ResultsNine hundred sixty-four patients with rib fracture(s) were admitted. Of these, 73 had a pain management consult. Thirteen had epidural catheters and 25 had ESPBs placed. There was no difference in demographics, injury patterns, bleeding complications, or venous thromboembolism rates among the groups. Patients with ESPB were less likely to have a dose of chemoprophylaxis held because of placement of a catheter (25% versus 100%, P < 0.00001). Three patients with ESPB were on oral anticoagulation on admission, and two were able to continue their regimen during placement. ConclusionsESPB can be safely placed in patients on chemoprophylaxis. It should be considered over traditional blocks in patients with blunt chest wall trauma because of its technical ease and ability to be performed with chemoprophylaxis.

Venous thrombosis risk factors in pregnant women.

Assess all risk factors of venous thromboembolism (VTE) in pregnancy and puerperium. Different guidelines for VTE prevention have been analyzed. Various recommendations have appeared for practitioners during the last 10-15 years on the basis of the risk factors analysis in order to prevent VTE in pregnant women more effectively. Nevertheless, none of these recommendations can yet take into account all risk factors, although convenient scoring systems have emerged for risk assessment and clear recommendations on anti-thrombotic prophylaxis regimens in risk groups in recent years. VTE is the third most common cause of death on Earth after myocardial infarctions and strokes, according to the World Health Organization. Pregnancy is a unique condition of woman, when enormous changes occur in functioning of the most important systems of homeostasis in a relatively short time. These are physiological hypercoagulation, slowing of blood flow, increase in circulating blood volume, etc. However, while being physiological, these changes increase the risks of venous thromboembolism by almost six times. In some cases, there appears an imbalance or dissociation between the functioning of natural antithrombotic systems and the activation of coagulation as a consequence of genetically or acquired determined causes (genetic thrombophilia, antiphospholipid syndrome, comorbidities, obstetric complications and other exogenous and endogenous factors). Accordingly, identification of risk factors, their systematization, and determination of VTE risks in pregnancy and puerperium is one of the most important tasks of clinical medicine. This article will review historical understanding of thrombosis in pregnant women, progress in understanding VTE risk factors in pregnant women, and available reserves in identifying new risk factors during pregnancy and puerperium in order to stratify risks more efficiently.

Prognostic factors for VTE and bleeding in hospitalized medical patients: a systematic review and meta-analysis

AbstractThere may be many predictors of venous thromboembolism (VTE) and bleeding in hospitalized medical patients, but until now, systematic reviews and assessments of the certainty of the evidence have not been published. We conducted a systematic review to identify prognostic factors for VTE and bleeding in hospitalized medical patients and searched Medline and EMBASE from inception through May 2018. We considered studies that identified potential prognostic factors for VTE and bleeding in hospitalized adult medical patients. Reviewers extracted data in duplicate and independently and assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. Of 69 410 citations, we included 17 studies in our analysis: 14 that reported on VTE, and 3 that reported on bleeding. For VTE, moderate-certainty evidence showed a probable association with older age; elevated C-reactive protein (CRP), D-dimer, and fibrinogen levels; tachycardia; thrombocytosis; leukocytosis; fever; leg edema; lower Barthel Index (BI) score; immobility; paresis; previous history of VTE; thrombophilia; malignancy; critical illness; and infections. For bleeding, moderate-certainty evidence showed a probable association with older age, sex, anemia, obesity, low hemoglobin, gastroduodenal ulcers, rehospitalization, critical illness, thrombocytopenia, blood dyscrasias, hepatic disease, renal failure, antithrombotic medication, and presence of a central venous catheter. Elevated CRP, a lower BI, a history of malignancy, and elevated heart rate are not included in most VTE risk assessment models. This study informs risk prediction in the management of hospitalized medical patients for VTE and bleeding; it also informs guidelines for VTE prevention and future research.

Quality Improvement at an Academic Cancer Center: Venous Thromboembolism Prophylaxis in Patients With Multiple Myeloma.

Patients with multiple myeloma are at elevated risk of venous thromboembolism (VTE), the second leading cause of death in patients with cancer, but physician adherence to VTE prevention guidelines is low. Several organizations partnered in designing and implementing a 2-year quality improvement (QI) program in a tertiary care/academic cancer center, to increase awareness of VTE prophylaxis for patients with multiple myeloma and thus improve adherence to prophylaxis guidelines and protocols. The QI arm included 2 chart audits, conducted 2 years apart, of unmatched cohorts of 100 patients with multiple myeloma. An Education arm included 2 grand rounds presentations, 3 web-based case discussions, and a patient education module. Twenty providers took part in the continuous QI arm. More than 1100 learners participated in the online cases; the patient education curriculum reached 112 multiple myeloma patients. The initiative proved helpful in defining barriers to guideline adherence and identifying data-driven practice improvement strategies for VTE prophylaxis. It also increased learner awareness of VTE guidelines, patient risk stratification, and optimal thromboprophylaxis strategies. There was a reduction in VTE events (primary clinical outcome) from 10% at baseline to 4% in the follow-up cohort, although this was not statistically significant. Higher rates of guideline-based prophylaxis were observed in low-risk patients, and a lower incidence of VTE was observed in multiple myeloma patients with a prior history of VTE. Additional research is needed to refine prophylaxis guidelines. With appropriate institutional support, this type of QI program can be readily adopted by other organizations to address practice improvement needs.

The changes in preferences for venous thromboembolism prophylaxis after total joint arthroplasty in Turkey: A survey.

This study aims to investigate the changes in preferences of orthopedic surgeons for venous thromboembolism (VTE) prophylaxis after total knee arthroplasty (TKA) and total hip arthroplasty (THA) and the factors that affect such changes in Turkey. Turkish Orthopedics and Traumatology Association members (n=2,180) were invited to fill in the questionnaire. A total of 366 orthopedic surgeons responded and completed questionnaire. The questionnaire was comprised of 12 questions investigating the demographics of surgeons, their preferences for VTE prophylaxis, the changes in their preferences over the course of the past three years, and the causes of such changes. In the past three years, 31.1% of surgeons changed their VTE prophylaxis method and 32.7% used risk classifications. The use of low molecular weight heparin (LMWH) decreased from 89.4% to 42.5% and from 85.8% to 44.2% after TKA and THA, respectively. The use of aspirin increased from 10.6% to 43.4% and from 9.7% to 37.2% after TKA and THA, respectively. The use of oral anticoagulants increased from 11.5% to 41.6% and from 10.6% to 39.8% after TKA and THA, respectively. Still, orthopedic surgeons in Turkey preferred LMWH at rates of 75.7% and 74% after TKA and THA, respectively. Congressional presentations were the first (47.7%) among the causes of the changes in preferences for VTE prophylaxis. Preferences of up to 60% of surgeons working at universities were influenced by the American Academy of Orthopedic Surgeons guidelines. In the past three years, approximately one third of orthopedic surgeons changed their preferences for VTE prophylaxis after total joint arthroplasty in Turkey. Changes in preferences were largely in favor of aspirin and oral anticoagulants in parallel to changes in guidelines for VTE prevention.

Venous thromboembolism prophylaxis after hip preservation surgery: a review and presentation of institutional experience.

ABSTRACTVenous thromboembolism (VTE) is a serious complication after major orthopedic procedures. The best options for prevention of the VTE are still debated. The most popular evidence-based guidelines for prevention and treatment of VTE in orthopedic surgery addressed the total hip or knee arthroplasty and hip fractures as the major orthopedic surgeries. Majority of studies have evaluated the different modalities of the VTE prophylaxis in patients undergiong hip or knee arthroplasty. Hip preservation surgeries (HPS) including mini-open femoroacetabular osteoplasty, surgical dislocation of the hip, arthroscopic procedures, and periacetabular osteotomy (PAO) are gained popularity in recent two decades. The majority of these patients are young, healthy and active and may not be considered at high risk for VTE. The frequency of VTE in patients undergoing PAO seems to be low between 0 and 5%. There is a paucity of data regarding rates of VTE in young healthy patients undergoing HPS as well as the optimal prevention methods for VTE. Hence current VTE prevention guidelines do not cover HPS adequately. We aimed to review the available literature regarding VTE events and VTE prophylaxis options after HPS. We discussed the available and potential options for prophylaxis of VTE events in these procedures along with our experience in a large cohort of hip preservation surgery.

Evaluation of a nurse-led intervention to improve adherence to recommended guidelines for prevention of venous thromboembolism for hip and knee arthroplasty patients: A quasi-experimental study.

To measure adherence to a nurse-led evidence-based venous thromboembolism prevention programme (intervention) compared to usual care in hip and knee arthroplasty patients and associated clinical outcomes. Venous thromboembolism morbidity and mortality of hospitalised patients is a major concern for health professionals. Venous thromboembolism prevention guidelines have been developed; however, adherence to guidelines is variable. There were 410 potential participants who were adult patients that were booked for elective hip or knee arthroplasty at the two study sites during a 2-year period (2011-2013). Of these, 27 did not meet the inclusion criteria, and the remainder were eligible for inclusion in the study (intervention site n=196 and control site n=187, total population n=383). This study adopted a quasi-experimental design, using an intervention and control study site, conducted in two private hospitals in a regional area in Australia. The intervention group had a mean compliance score of 11.09, higher than the control group score of 7.19. This is equivalent to a compliance rate of 85% and 55%, respectively, and indicates that adherence at the study site was significantly higher. Patient adherence and outcomes in the postdischarge period were not significantly different between the study sites. This study demonstrated a nurse-led intervention achieved high adherence with translating evidence-based guidelines into routine patient care for hip and knee arthroplasty patients. Nurses can be critical to implementing clinical practice guidelines and adopting preventive programmes in acute care to improve patient outcomes and reduce postoperative venous thromboembolism in arthroplasty patients. This research demonstrates the capacity of nurses to lead the translation of evidence-based practice guidelines for prevention of venous thromboembolism into routine patient care.

Outline of new venous thromboembolism prevention guidelines in patients undergoing orthopedic surgery: Circumstances and history of preparing the guideline

要約：2017 年に日本整形外科学会の症候性VTE 予防ガイドラインが発刊された．それまでのガイドラインでは，予防対象は「無症候性VTE を含む全てのVTE」であったが，新ガイドラインでは予防対象を「症候性VTE」に変更した．これは患者にとって重要な結果は無症候性VTE の減少ではなく，症候性VTE・致死性PTE と出血合併症であるという国際的ガイドラインの動向にも沿ったものである．予防対象を変更したことで，エビデンスが乏しくなりエビデンスレベルを併記した推奨はできなかった．また，これまでのわかりやすいリスク分類や予防法の表を排除した．これは一覧表が医療訴訟に安易に使用されてきたことを鑑みたものである．医療安全を意識した執筆を心がけ，基本的で安全性が高い理学的予防法，早期歩行を重視．抗凝固療法を適応する場合は，患者の個別的状況に応じて，VTE リスクと出血リスクとのバランスを考慮する必要があることを強調している．

Venous Thromboembolism Audit; where are we now and how can we improve?

Introduction: Venous Thromboembolism (VTE) is the term used to describe blood clots in the deep veins. It is considered to be a significant healthcare topic due to the high incidence in hospitalised patients. National body in the UK (NICE) recommends risk assessment, the appropriate prescription of thromboprophylaxis and the provision of patient information to all patients over the age of 18 years admitted to hospital. Despite the introduction of national guidance, patients develop hospital related VTE. It is therefore essential to establish compliance of VTE prevention policy and provide recommendations where improvements are necessary. Purpose: To assess current practice within an acute hospital in reducing the risk of VTE in patients admitted to hospital against NICE guidance and to identify methods of improvement to ensure adherence to VTE prevention guidelines. Materials and methods: A local audit was carried out using a tool which was designed to measure clinical practice against national standards for VTE prevention. PDSA cycle was used for a systematic process to be followed. A snapshot sample of 60 inpatient records was selected to be audited on medical and surgical wards of an acute trust. Data was analysed using excel, histograms were produced and percentages calculated to identify adherence of VTE prevention policy in practice. Results: The audit found that 67% (n=40/60) audit proformas were completed in the allocated time frame; 88% (n=35) of patients had a recorded risk assessed for VTE and bleeding on admission to hospital. Only 18% (n=7) of patients in the audit received verbal information on VTE prevention on admission and none received written information. Furthermore, 10% (n=4) of patients who required anti- embolism stockings did not receive them and 40% (n=16) of patients did not receive appropriate chemical thromboprophylaxis. Conclusion: Risk assessment and administration of prevention methods can considerably reduce the risks of patients developing VTE thus enhancing patient safety and quality of care provided by the healthcare sector. This audit demonstrates inconsistencies in providing correct VTE prevention methods to patients throughout an acute hospital trust and highlights key recommendations for improvement.

Venous Thromboembolism: A Comparison of Chronic Spinal Cord Injury and General Surgery Patients in a Metropolitan Veterans Affairs Hospital.

Venous thromboembolic events result in significant morbidity, mortality, and costly therapeutic interventions. As medical resource allocation strategies are becoming more pervasive, appropriate risk stratification and prophylactic regimens are essential. Previous studies have shown a decreased incidence of perioperative venous thromboembolism in the chronic spinal cord injury population. The question remains of whether chronic spinal cord injury is protective against venous thromboembolism. A retrospective review of all cases involving chronic spinal cord injury patients who underwent plastic and reconstructive surgery operations (n = 424) and general surgery patients (n = 777) with a primary outcome of deep venous thrombosis or pulmonary embolism within 90 days of surgery was performed. The incidence of postoperative deep venous thrombosis in the control and spinal cord injury groups was 1.7 percent and 0.2 percent, respectively (p = 0.027). However, such significance was not observed with regard to postoperative pulmonary embolism incidence (p = 0.070). Collectively, the incidence of postoperative venous thromboembolism-specifically, deep venous thrombosis or pulmonary embolism-was significantly greater in the general surgery population (p = 0.014). A nearly 10-fold increased risk of venous thromboembolism was seen among the control group (1.9 percent versus 0.2 percent) despite administration of optimal prophylaxis. This study demonstrates a profoundly low incidence of venous thromboembolism among chronic spinal cord injury patients compared with general surgery patients. Future efforts to elucidate how chronic spinal cord injury confers a protective mechanism may potentially influence the evolution of venous thromboembolism prevention guidelines, and spark the development of alternative prophylactic agents or customized application of prevention efforts.

Another Maternal Safety Bundle: Obstetric Venous Thromboembolism

Sponsoring Organization: Council on Patient Safety in Women's Health Care Target Population: Obstetric care providers Background and Objective Obstetric venous thromboembolism (VTE) is a common threat to maternal and fetal wellbeing, yet guidelines for VTE prevention have varied among professional societies. The National Partnership for Maternal Safety (NPMS) convened leaders to develop a bundle of evidence-based recommendations. Like the bundle for obstetric hemorrhage (NEJM JW Womens Health Aug 2015 and Obstet Gynecol 2015; 126:155), …

Preventable vs Non-Preventable VTE in Hospitalized Patients

SESSION TITLE: Education SESSION TYPE: Original Investigation Slide PRESENTED ON: Tuesday, October 25, 2016 at 02:45 PM - 04:15 PM PURPOSE: Currently venous thromboembolism (VTE) is still considered a common preventable condition in hospitalized patients. However a significant proportion of VTE cases occur in patients who have received appropriate prophylactic measures according to the current guidelines. Financial implications for healthcare institutions for quality performance and costs incurred from the event can be substantial. We propose a classification system for preventable VTE versus non-preventable VTE cases based on compliance with appropriate prophylaxis based on current evidenced based guidelines. METHODS: Patients with hospital acquired VTE were identified in an academic tertiary care center. 120 cases during January 2015 to February 2016 were randomly selected for analysis for adherence to VTE prophylaxis guidelines. VTE prophylaxis compliance was based on American College of Chest Physicians 9th edition (ACCP) guidelines. Prescription order compliance was defined by appropriate pharmacological and/or mechanical prophylaxis being prescribed for the patient if indicated. Mechanical prophylaxis compliance was defined as appropriate adherence to mechanical prophylaxis during the indicated period. Pharmacological prophylaxis compliance was defined as appropriate dosing being administered during the indicated period. If there was full compliance with the measures, then health care delivery was termed as ‘optimal’ or defect-free. If any hospitalized patients develop VTE despite optimal care, it was classified as potentially non-preventable VTE. If any lapse in adherence to the guidelines was identified, it was termed as ‘sub-optimal’ care. The VTE cases resulting from sub-optimal care were classified as potentially preventable. An algorithm for classification of Hospital Acquired VTEs was developed using the above defined compliance measures. RESULTS: One hundred and twenty hospital acquired venous thromboembolism events were analyzed. 42 of 120 (35%) VTE cases are potentially preventable and 78 of 120 (65%) are potentially non-preventable. Pharmacological prophylaxis was ordered in 97.5% and mechanical prophylaxis was ordered in 89.16% prior to the development of VTE. Gap in pharmacological prophylaxis was found in 16 cases (13.33%), 15 cases (12.5%) had gap in mechanical prophylaxis and gaps in pharmacological and mechanical prophylaxis was found in 11 cases (9.12%). CONCLUSIONS: Majority (65%) of hospital acquired VTEs are Non-Preventable based on compliance with the 9th edition ACCP Guidelines for VTE prevention. CLINICAL IMPLICATIONS: Quality performance measures should target preventable VTE events rather than all hospital acquired VTE episodes. DISCLOSURE: The following authors have nothing to disclose: Shekhar Patil, Mary Ayad, Shethia Maithili, Bela Patel No Product/Research Disclosure Information

Meta-analysis and suggested guidelines for prevention of venous thromboembolism (VTE) in foot and ankle surgery.

Purpose To perform a meta-analysis investigating venous thromboembolism (VTE) following isolated foot and ankle surgery and propose guidelines for VTE prevention in this group of patients.MethodsFollowing a PRISMA compliant search, 372 papers were identified and meta-analysis performed on 22 papers using the Critical Appraisal Skills Programme and Centre for Evidence-Based Medicine level of evidence.Results 43,381 patients were clinically assessed for VTE and the incidence with and without chemoprophylaxis was 0.6 % (95 % CI 0.4–0.8 %) and 1 % (95 % CI 0.2–1.7 %), respectively. 1666 Patients were assessed radiologically and the incidence of VTE with and without chemoprophylaxis was 12.5 % (95 % CI 6.8–18.2 %) and 10.5 % (95 % CI 5.0–15.9 %), respectively. There was no significant difference in the rates of VTE with or without chemoprophylaxis whether assessed clinically or by radiological criteria. The risk of VTE in those patients with Achilles tendon rupture was greater with a clinical incidence of 7 % (95 % CI 5.5–8.5 %) and radiological incidence of 35.3 % (95 % CI 26.4–44.3 %).ConclusionIsolated foot and ankle surgery has a lower incidence of clinically apparent VTE when compared to general lower limb procedures, and this rate is not significantly reduced using low molecular weight heparin. The incidence of VTE following Achilles tendon rupture is high whether treated surgically or conservatively. With the exception of those with Achilles tendon rupture, routine use of chemical VTE prophylaxis is not justified in those undergoing isolated foot and ankle surgery, but patient-specific risk factors for VTE should be used to assess patients individually.Level of evidenceII.

Current Practice of Hospital Acquired Thrombosis (HAT) Prevention in an Acute Hospital (a single centre cross sectional study)

BackgroundEvidence based consensus guidelines for venous thromboembolism (VTE) prevention are broadly accepted to be effective and safe for more than three decades (Clagett GP et al, 1992). However VTE continues to be associated with a major global burden of disease with 3.9 million cases of HAT during one year among 1.1 billion citizens of high income countries (Jha AK et al, 2013). Therefore prevention is the key to reduce death and disability resulting from VTE (Kahn S et al, Gould MK et al & Falck-Yitter Y et al, 2012). Ireland like many other countries has yet to implement a mandatory risk assessment tool and thromboprophylaxis (TP) policy nationally.AimsThe aim of this study was to calculate the proportion of inpatients who had a VTE risk assessment performed and received appropriate TP in a large tertiary referral hospital. This information will be vital for baseline data for implementation of a new national policy for prevention of HAT.MethodsThis audit was performed at Cork University Hospital on 4 pre specified days between November 2014 to February 2015. All adult inpatients (Medical and Surgical) excluding maternity and psychiatric were included. Patients on therapeutic anticoagulation were also excluded. The patients' medical chart and drug prescription chart were reviewed to determine whether or not a VTE risk assessment was documented for each patient and if they had received appropriate TP. If no risk assessment had been performed, trained researchers applied the National Institute for health and Care Excellence (NICE) guidelines 92 (Jan 2010) for VTE risk assessment and prevention.Following the risk assessment patients were divided into three categories, high risk of VTE with low risk of bleeding; high risk of VTE with significant risk of bleeding and low risk of VTE. From this the proportion of patients in each group that received appropriate TP were calculated.ResultsA total of 1019 patients were enrolled the majority were medical patients 63.5% (n=648). The mean age of patients was 69 years. Females accounted for 52% of patients. Average length of hospitalisation for each patient at the time of the audit was 6 days (range 1-664 days).Overall, a formal TP risk assessment was documented in only 24% (n=244) of all charts reviewed however TP was prescribed in 43.2% (n=441) of patients. See table. Table 1High Risk of VTE low risk of bleedingHigh risk of VTE significant risk of bleedingLow risk of VTENo. of pts80.3% (n=819)16.6% (n=170)2.9% (n=30)VTE risk assessment documented21.9% (n=180)28.2% (n=55)30% (n=9)Received TP46.3% (n=380)28.8% (n=49)40% (n=12)Within the high risk category patients, 64.3% (n=526) medical. TP was only administered to 46.3% (n=380) of patients in the high risk category. This was almost evenly distributed between surgical 50.1% (n=147) and medical 43.4% (n=233) patients.ConclusionThis audit was done as the initial step to develop a national policy to prevent HAT. As suspected, this audit highlights that a large proportion of hospitalised patients, both surgical and medical, continue to be at high risk for VTE despite the availability of preventative measures.There is clear illustration of under prescription of safe, effective and recommended means of VTE prevention. The current overall figure of less than 50% prescription of VTE thromboprophylaxis in high risk patients is a major patient safety concern. There are numerous recognised international guidelines for prevention of VTE, and an efficient method to implement these guidelines needs to be developed. Beyond developing national guidelines for TP, we need a co-ordinated approach to implement and monitor compliance with guidelines.Once the preliminary results of this audit were available to us in March 2015, urgent measures were taken to reduce the identified risk such as the establishment of a Hospital Thrombosis Group which developed a user friendly VTE risk assessment tool and TP policy. The VTE risk assessment tool was incorporated into the patients drug prescription chart and included a pre printed prescription for TP. It is now mandatory for the all patients to have a VTE risk assessment tool and TP prescribed if appropriate within 24hrs of admission. This was successfully piloted for four weeks in the acute medical assessment unit and is now incorporated into each patients drug chart throughout the hospital. This audit will be replicated in 6 months from introduction of this initiative, with an aim of >90% compliance. DisclosuresNo relevant conflicts of interest to declare.

Methods and Guidelines for Venous Thromboembolism Prevention in Polytrauma Patients with Pelvic and Acetabular Fractures.

Sequential compression devices and chemical prophylaxis are the standard venous thromboembolism (VTE) prevention for trauma patients with acetabular and pelvic fractures. Current chemical pharmacological contemplates the use of heparins or fondaparinux. Other anticoagulants include coumarins and aspirin, however these oral agents can be challenging to administer and may need monitoring. When contraindications to anticoagulation in high-risk patients are present, prophylactic inferior vena cava filters can be an option to prevent pulmonary emboli. Unfortunately strong evidence about the most effective method, and the timing of their commencement, in patients with pelvic and acetabular fractures remains controversial.

Aspirin and venous thromboses

The pharmacological prevention of venous thromboembolism (VTE) has so far been carried out mainly with classic (low-molecular-weight heparins, coumarins) or new direct oral anticoagulants (DOACs). The role of antiplatelet treatment with aspirin is controversial. New data, however, suggest a paradigm shift with the reassessment of aspirin as part of a multimodal antithrombotic approach. The article provides an up-to-date overview of the role of antiplatelet treatment with aspirin in the primary and secondary prevention of VTE. Primary prevention of surgery-related VTE with anticoagulants is effective but apparently not superior to a multimodal approach with aspirin, pneumatic compression, and early mobilization. Against this background, aspirin is now also included in the VTE prevention guidelines in the US (ACCP, AAOS) but not in the UK (NICE) and Germany (AMWF). A final evaluation of aspirin as compared to classic anticoagulants and DOACs in primary prophylaxis requires further randomized controlled, prospective trials. These should also consider the iatrogenic risk of bleeding as well as possible postoperative complications, such as retarded wound healing that might require prolonged hospitalization. After ending guideline-conforming anticoagulant treatment in patients with idiopathic VTE, administration of aspirin reduces the risk of recurrent VTE by about 40% without increasing the risk of severe bleeding (standardized INSPIRE evaluation of ASPIRE and WARFASA data). These data add to the current use of aspirin in the prevention of arterial thrombosis the new option of preventing spontaneous VTE. On the basis of new data from recent studies, an indication can be made for the use of aspirin, combined with other preventive measures, in the prevention of primary and secondary venous thromboses.