Prevention Of Venous Thromboembolism Research Articles

Update on the Pharmacological Actions of Enoxaparin in Nonsurgical Patients.

Low-molecular-weight heparins are a class of drugs derived from the enzymatic depolymerization of unfractionated heparin that includes enoxaparin. Several studies have been performed on enoxaparin in recent years, in particular for the prevention and treatment of venous thromboembolism and for the treatment of acute coronary syndrome. Furthermore, the use of enoxaparin has been extended to other clinical situations that require antithrombotic pharmacological prevention, such as hemodialysis and recurrent abortion. In this review, we report the main clinical experiences of using enoxaparin in the prevention of VTE in nonsurgical patients.

High microRNA-145 plasma levels are associated with decreased risk of future incident venous thromboembolism: the HUNT study

AbstractMicroRNA-145 (miR-145) has been reported to downregulate the expression of tissue factor and factor XI in vitro and decrease venous thrombus formation in animal models. However, the association between miR-145 and risk of future venous thromboembolism (VTE) in the general population remains unknown. We investigated the association between plasma levels of miR-145 and risk of future VTE in a case-cohort study. Incident VTE cases (n = 510) and a subcohort (n = 1890) were derived from the third survey of the Trøndelag Health Study (HUNT3), a population-based cohort. The expression levels of miR-145 were measured in plasma samples obtained at baseline. The study population was divided into quartiles based on miR-145 levels in participants in the subcohort, and weighted Cox regression was used to estimate hazard ratios (HRs) with 95% confidence intervals (CIs). Plasma levels of miR-145 were inversely associated with VTE risk. Participants with miR-145 levels in the highest quartile had a 49% lower risk of VTE (HR, 0.51; 95% CI, 0.38-0.68) than those with miR-145 in the lowest quartile in age- and sex-adjusted analysis, and the inverse association was most pronounced for unprovoked VTE (HR, 0.39; 95% CI, 0.25-0.61). Risk estimates remained virtually the same after further adjustment for body mass index, and cancer and arterial cardiovascular disease at baseline. In conclusion, elevated expression levels of miR-145 in plasma were associated with decreased risk of future incident VTE. The protective role of miR-145 against VTE is consistent with previous experimental data and suggests that miR-145 has the potential to be a target for VTE prevention.

Prevention of venous thromboembolism in surgical patients: A proposal for a protocol based on the reality of a university hospital

Introduction: Venous thromboembolism (VTE) results from the formation of thrombi in the endothelial space, following factors related to endothelial injury, venous stasis and coagulation disorders. This scenario can result in deep vein thrombosis (DVT) and pulmonary thromboembolism (PTE), which is the third leading cause of cardiovascular death worldwide. Given the possibility of preventing VTE in the majority of in-hospital cases, it is recommended that every hospital has a formal strategy for VTE prevention, including in patients undergoing elective surgery. To this end, it is possible to use risk stratification scales, both for the development of VTE and the baseline risk of bleeding in post-operative patients. Objective: To provide an institutional protocol that is systematized and updated according to the main national and international literature on the prevention of venous thromboembolism in elective surgeries at the Júlio Muller University Hospital (HUJM/ UFMT). Materials and Methods: A protocol was drawn up based on a systematic analysis of up-to-date scientific evidence on thromboprophylaxis in elective surgeries, adapted to the routine of the Júlio Muller University Hospital (HUJM/UFMT), using the UpToDate, Pubmed and Cochrane Library platforms, as well as the Guidelines of the Brazilian Society of Angiology and Vascular Surgery (SBACV) and the American College of Chest Physicians (ACCP). Conclusion: The patient's risk of developing VTE is largely due to avoidable or predictable risk factors, depending on the type of surgery, mobilization time and risk of bleeding. The use of a protocol for the prevention of venous thromboembolism through risk stratification will allow greater individualization of the patient in relation to established prophylaxis, based on scientific evidence. Further studies on the subject are still needed, especially in the setting of elective surgery.

Venous Thromboembolism in Children: The Rivaroxaban Experience.

The incidence of venous thromboembolism (VTE) in the pediatric population has increased more than 10-fold in the last 20 years, as a consequence of the advancement of resuscitation and surgical techniques and the global increase in life expectancy of children suffering from chronic pathologies. Monitoring anticoagulant therapy to achieve outcomes within the target range in childhood VTE, parenteral administration of medications, and frequent blood tests in children are often cumbersome. Availability of safe and effective oral agents with pediatric data to support use would be of clear benefit. A physiologically based pharmacokinetic model was developed to estimate the appropriate dosing schedule for rivaroxaban in children. This incorporated growth/maturation and variability in anthropometrics (e.g., body height, weight, and body mass index), anatomy (e.g., organ weight), physiology (e.g., blood flow rates), metabolism and excretion. Rivaroxaban use in pediatric population underwent a complete investigational program, consisting mainly of one phase I pharmacokinetics/pharmacodynamics trial, three phase II trials, one phase III trial. The phase III trial enrolled 500 patients from birth to <18 years and documented the efficacy and safety of rivaroxaban regimens at dose equivalent to the adult 20 mg dose for the prevention of fatal or symptomatic nonfatal recurrent VTE and major bleeding versus heparin or vitamin K antagonists. Results were similar to those in rivaroxaban studies in adults. The efficacy and safety of rivaroxaban in children reported in the EINSTEIN JUNIOR trial provide further support to previous trials in adults (EINSTEIN Program), which demonstrate a favorable profile for the use of rivaroxaban for the management of VTE in challenging patient populations. Other clinical evidence contributing to the use of rivaroxaban among different risk groups in pediatric VTE population confirms the consistency with principal trial. Our review aims to describe the rationale for using rivaroxaban oral suspension in clinical practice and to summarize its multiple indications in each vascular bed (e.g., cerebral venous thrombosis, symptomatic or asymptomatic central venous catheter-associated thrombosis), etiology, and patients setting.

Effect of a Self-instructional Module on Clinical Nurses’ Knowledge and Practice Regarding Prevention of Venous Thromboembolism in Post-operative Patients

Abstract This pre-experimental study was done to assess the effect of a self-instructional module on clinical nurses’ knowledge and practice regarding the prevention of venous thromboembolism (VTE) in post-operative patients. The sample consists of 30 clinical nurses working in post-operative ICUs selected by purposive sampling technique. The tools used were a self-administered structured questionnaire on socio-demographic data and knowledge and an observation checklist on practice regarding the prevention of VTE. The study findings revealed that there was a significant difference between the pre-test and post-test knowledge and practice scores as the mean knowledge score of the post-test (16.93 ± 2.82) is higher than the pre-test score (13.70 ± 3.35) and the mean practice score of post-test (3.06 ± 1.17) is higher than the pre-test score (2.16 ± 0.74). There was a weak positive correlation between knowledge and practice scores (r = 0.08). The study findings also showed that there was no significant association between the pre-test level of knowledge and practice with selected demographic variables such as age, gender, qualification, total years of experience, previous knowledge on VTE and source of information. It can be concluded that the self-instructional module is effective in improving the knowledge and practice of clinical nurses in the prevention of VTE.

Effect of venous foot pump intervention on prevention of venous thromboembolism in patients with major orthopedic surgery: a systematic review and meta-analysis.

Venous thromboembolism (VTE) is a common complication after major orthopedic surgery. The venous foot pump (VFP) is an effective mechanical preventive measure against VTE in patients. However, the differences in effectiveness based on varying usage times of VFP remain unclear. To explore the effectiveness of VFP with different usage times in preventing VTE in patients undergoing major orthopedic surgery. Nine databases (PubMed, Web of Science, CINAHL, Embase, Cochrane Library, CBM, VIP, CNKI, and Wanfang) were searched to identify randomized controlled trials (RCTs) evaluating VFP interventions for VTE prevention in major orthopedic surgery patients. The risk of bias in each study was assessed using the Cochrane Collaboration tool. Meta-analysis was conducted using RevMan 5.3. A total of 36 RCTs involving 3,791 patients undergoing major orthopedic surgery were included. Meta-analysis revealed significant differences in VTE incidence between the VFP and blank control groups (RR = 0.27, 95% confidence interval CI: 0.19-0.38, P < 0.001) and between the VFP plus chemoprophylaxis and chemoprophylaxis alone groups (RR 0.39, 95% CI: 0.29-0.53, P < 0.001). However, no statistically significant difference was observed between the VFP and the LMWH groups (RR = 0.93, 95% CI: 0.54-1.61, P = 0.8). Subgroup analysis showed no significant difference in effectiveness based on different VFP usage durations (VFP vs. Blank: Chi-square = 0.54, P = 0.46, I2 = 0%; VFP Plus chemoprophylaxis vs. chemoprophylaxis alone: Chi-square = 1.93, P = 0.86, I2 = 0%). The current evidence indicates that VFP significantly reduces the incidence of postoperative VTE in patients undergoing major orthopedic surgery. VFP can be considered an add-on strategy to LMWH for patients at low risk of bleeding and an alternative strategy to LMWH in patients at high risk of bleeding. This study found no significant difference in effectiveness between various VFP usage interventions. Future research should focus on economic cost-effectiveness and patient acceptance to help policymakers determine the most efficient usage duration, providing practical guidance for thromboprophylaxis.

Prevention and control of venous thromboembolism after major orthopedic surgery through doctor-to-patient cultivation of musculoskeletal ability based on King's theory of goal attainment.

To explore the prevention and management of venous thromboembolism (VTE) following major orthopaedic surgery (MOS) by fostering doctor-to-patient cultivation of musculoskeletal ability, guided by King's theory of goal attainment. A cohort of patients (n = 116) undergoing MOS was selected for the study, and were divided into two groups: the regular group and the observation group, with patients in the regular group experiencing routine nursing care and management and those in the observation group undergoing musculoskeletal ability cultivation based on King's theory of goal attainment. Baseline data, limb vascular ultrasonography, coagulation function, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, VTE prevention efficacy, Exercise of Self-care Ability Scale (ESCA) score, and nursing satisfaction were analysed comparatively. There was no significant within-group difference in baseline data (P > 0.05). Following the interventions, the observation group demonstrated statistically significant reductions in the Musculoskeletal-Integrated Imaging Score, various dimensions of WOMAC scores, and D-dimer (D-D) levels (P < 0.05) both in comparison to their levels before interventions and to those observed in the regular group (P < 0.05). Additionally, the observation group exhibited increases in prothrombin time levels and various dimensions of ESCA scores (P < 0.05) post-intervention, surpassing the pre-intervention levels and those obtained in the regular group (P < 0.05). Furthermore, the observation group exhibited a significantly lower incidence of VTE (P < 0.05) and higher nursing satisfaction (P < 0.05) compared to the regular group. Nursing intervention measures, utilizing doctor-to-patient cultivation of musculoskeletal ability based on King's theory of goal attainment, have demonstrated a significant clinical benefit for VTE prevention and control in post-MOS patients. This approach not only effectively prevented VTE in post MOS patients but also enhanced their satisfaction towards nursing care.

Efficacy and safety of direct oral anticoagulants for preventing venous thromboembolism in hospitalized cancer patients: a national multicenter retrospective cohort study.

Studies on the use of direct oral anticoagulants (DOACs) for preventing venous thromboembolism (VTE) in hospitalized cancer patients are lacking. Therefore, we conducted a multicenter retrospective cohort study to evaluate the efficacy and safety of DOACs versus low-molecular-weight heparin (LMWH) for the primary prevention of VTE in hospitalized cancer patients. Clinical outcomes included thrombosis, VTE, other thrombosis, all bleeding, major bleeding, nonmajor bleeding, and all-cause death. A 1:1 cohort of rivaroxaban and LMWH patients was created by propensity score matching. A total of 2,385 cancer patients were included in this study. During the 3-month follow-up period, 129 (5.4%) thrombosis events occurred, 63 (2.7%) of which were VTEs and 66 (2.8%) of which were other thrombosis events. All bleeding occurred in 163 (6.8%) patients, 68 (2.9%) had major bleeding, and 95 (4.0%) had nonmajor bleeding. All-cause deaths occurred in 113 (4.7%) patients. After adjusting for various confounders, the incidence of thrombosis and other thromboses was significantly lower in the rivaroxaban group than in the LMWH group [OR 0.543, 95% CI (0.343-0.859), p = 0.009; OR 0.461, 95% CI (0.241-0.883), p = 0.020]. There were no significant differences in incidence of VTE, total bleeding, major bleeding, nonmajor bleeding, or all-cause death. In oncology patients receiving thromboprophylaxis, rivaroxaban has a lower incidence of thrombosis and other thrombosis and a similar incidence of VTE as LMWH and does not increase the risk of bleeding. Rivaroxaban may be an attractive alternative to LMWH for preventing VTE in hospitalized cancer patients.

Effect of heparin for the prevention of venous thromboembolism in patients with spontaneous intracranial cerebral hemorrhage: a meta-analysis.

Venous thromboembolism (VTE) has a serious impact on the prognosis of patients with spontaneous intracranial hemorrhage (sICH). However, the use of prophylactic heparin remains controversial. This study investigated the safety and timing of prophylactic heparin for VTE in patients with sICH. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. Two authors systematically searched Web of Science, Cochrane Library, Embase, and PubMed to find all published research before June 2023. The incidence of deep venous thrombosis (DVT) and mortality were set as primary endpoints. This meta-analysis included seven randomized controlled trials (RCTs) and five observational studies involving a total of 4419 sICH patients in the heparin (n = 2808) and control (n = 1183) groups. Among these patients, 205 received early heparin administration, while 223 received late heparin administration. The results suggested that, compared to the control group, patients in the heparin group had a lower incidence of VTE [odds ratio (OR), 0.47; 95% CI, 0.31-0.71; p < 0.001], DVT (OR, 0.53; 95% CI, 0.33-0.85; p = 0.009), pulmonary embolism (OR, 0.31 95% CI, 0.15-0.65; p = 0.002), and mortality (OR, 0.70; 95% CI, 0.54-0.90; p = 0.006), but there were no statistical differences in hematoma enlargement, extracranial hematoma, and major disability (p > 0.05). There was no statistically significant difference in DVT, mortality, hematoma enlargement, and extracranial hemorrhage between the early heparin group (<24-48 h) and the late heparin group (p > 0.05). In patients with sICH, prophylactic use of heparin may be beneficial because it reduces the incidence of VTE and mortality without increasing the risk of additional bleeding. In addition, early prophylactic use of heparin appears to be safe. However, large-scale RCTs are lacking to support this evidence.

Retrospective cross-sectional analysis of concurrent VTE diagnosis in hospitalised socially excluded individuals in Ireland

ObjectiveSocial exclusion (such as that experienced by people who are homeless, incarcerated or use drugs) increases morbidity across a range of diseases but is poorly captured in routine data sets....

Serum Bilirubin Levels and Risk of Venous Thromboembolism among Influenza Patients: A Cohort Study.

This study aimed to investigate the associations between total serum bilirubin levels and the incidence of venous thromboembolism (VTE) among patients with influenza infection. A retrospective cohort study was conducted among outpatients with laboratory-confirmed influenza using data from the Veterans Affairs Informatics and Computing Infrastructure (VINCI). Propensity score weighting was applied to balance study groups across baseline covariates. Cox proportional hazards models assessed VTE risk by total bilirubin levels, adjusting for important covariates including age, sex, race, comorbidity index, BMI, and smoking status. A total of 487 patients with total bilirubin levels <0.3 mg/dL, 8608 patients with levels between 0.3-1 mg/dL, and 1148 patients with levels >1 mg/dL were included. Patients with bilirubin <0.3 mg/dL exhibited a 6-fold higher risk of VTE compared to those with levels 0.3-1 mg/dL within 30 days of infection (HR = 6.2, 95% CI = 1.46-26.42). Elevated risks were noted through 90 days post infection (HR = 4.71, 95% CI = (1.42-15.67)). Serum bilirubin levels, particularly below 0.3 mg/dL, were significantly associated with an increased risk of VTE among individuals with influenza. These findings suggest that lower bilirubin levels may contribute to heightened inflammatory responses and subsequent thromboembolic events in patients with influenza. The underlying mechanisms and potential therapeutic implications for VTE prevention among patients with acute respiratory infection warrants further consideration.

Risk Factors of Bleedings in Patients with COVID-19 Receiving Anticoagulants for Venous Thromboembolism Prevention

Risk Factors of Bleedings in Patients with COVID-19 Receiving Anticoagulants for Venous Thromboembolism Prevention

Application of integrated medical information management system in the risk assessment and prevention of perioperative venous thromboembolism in gynecological patients

Application of integrated medical information management system in the risk assessment and prevention of perioperative venous thromboembolism in gynecological patients

Nomogram for predicting venous thromboembolism after spinal surgery

PurposeThis study aimed to establish a nomogram to predict the risk of venous thromboembolism (VTE), identifying potential risk factors, and providing theoretical basis for prevention of VTE after spinal surgery.MethodsA retrospective analysis was conducted on 2754 patients who underwent spinal surgery. The general characteristics of the training group were initially screened using univariate logistic analysis, and the LASSO method was used for optimal prediction. Subsequently, multivariate logistic regression analysis was performed to identify independent risk factors for postoperative VTE in the training group, and a nomogram for predict risk of VTE was established. The discrimination, calibration, and clinical usefulness of the nomogram were separately evaluated using the C-index, receiver operating characteristic curve, calibration plot and clinical decision curve, and was validated using data from the validation group finally.ResultsMultivariate logistic regression analysis identified 10 independent risk factors for VTE after spinal surgery. A nomogram was established based on these independent risk factors. The C-index for the training and validation groups indicating high accuracy and stability of the model. The area under the receiver operating characteristic curve indicating excellent discrimination ability; the calibration curves showed outstanding calibration for both the training and validation groups. Decision curve analysis showed the clinical net benefit of using the nomogram could be maximized in the probability threshold range of 0.01–1.ConclusionPatients undergoing spinal surgery with elevated D-dimer levels, prolonger surgical, and cervical surgery have higher risk of VTE. The nomogram can provide a theoretical basis for clinicians to prevent VTE.

Rectus Sheath Hematoma Following Subcutaneous Enoxaparin Application: A Case Report

BACKGROUND: Thromboprophylaxis for prevention of venous thromboembolism has significantly decreased morbidity and mortality for post-operative patients over the previous decades. However, patients on anticoagulants are at risk for several major bleeding events, such as rectus sheath hematoma. Rectus sheath hematoma is an uncommon, potentially life-threatening complication that can be difficult to diagnose and easily confused with other abdominal pathologies. It most commonly occurs in patients on current prophylactic or therapeutic anticoagulants and can be spontaneous or provoked. Inadvertent damage to the rectus abdominis muscle or epigastric arteries during subcutaneous enoxaparin injection in the abdomen has been identified as a rare cause of this complication. THE CASE: A 68-year-old hospitalized female presented acute abdominal pain in the right lumbar and iliac region accompanied by hypotension and tachycardia eight days after uncomplicated total knee arthroplasty. She was found to have severe anemia on laboratory exam and a right rectus sheath hematoma on abdominal CT scan with a volume of 300cc. After the patient was stabilized via fluid resuscitation and blood transfusion, the hematoma was surgically drained. The surgeons involved noted possible inadvertent puncture of the right inferior epigastric artery during one of the patient’s bi-daily subcutaneous enoxaparin injections. CONCLUSION: This case report emphasizes the importance of recognizing rectus sheath hematoma as a potential complication of subcutaneous enoxaparin injection and the knowledge of its risk-factors and clinical presentation to make an early diagnosis and give adequate treatment.

A bibliometric analysis in venous thromboembolism nursing (1999–2022): Current status and future prospects

Research on venous thromboembolism (VTE) in nursing has garnered significant attention. This study aimed to examine the characteristics of VTE nursing publications, offering valuable insights into the current state of the field and forecasting future trends. A comprehensive screening of global publications up to 2022 was conducted using the Web of Science Core Collection database to investigate VTE nursing. The search incorporated keywords such as ‘venous thromboembolism’, ‘deep vein thrombosis’, and ‘pulmonary embolism’ to identify relevant studies. A bibliometric analysis of these publications was performed using various visualisation tools such as VOSviewer and R software. A total of 675 papers on VTE nursing were identified, with the earliest publication dating back to 1999. The research involved 971 institutions from 43 countries, with the United States leading by contributing to 261 articles. Harvard University emerged as the most productive institution, and Heit, with 17 publications, was the most cited author. The journal Thrombosis Research published the highest number of papers (11). The frontiers of VTE nursing research are anticipated to continue focusing on topics such as epidemiology, risk factors, and VTE prevention and management.

Prevention of venous thromboembolism in right heart-sided electrophysiological procedures: results of an European Heart Rhythm Association survey.

Limited data are available regarding venous thromboembolism (VTE), specifically deep vein thrombosis (DVT) and pulmonary embolism (PE), following right-sided ablations and electrophysiological (EP) studies. Compared to left-sided procedures, no guidelines on antithrombotic management strategies for the prevention of DVT and PE are available. The main purpose of the present European Heart Rhythm Association (EHRA) survey is to report the current management of right-sided EP procedures, focusing on anticoagulation and prevention of VTE. An online survey was conducted using the EHRA infrastructure. A total of 244 participants answered a 19-items questionnaire on the periprocedural management of EP studies and right-sided catheter ablations. The right femoral vein is the most common access for EP studies and right-sided procedures. An ultrasound-guided approach is employed by more than 2/3 of respondents. Intravenous heparin is not commonly given by the majority of participants. About 1/3 of participants (34%) routinely prescribe VTE prophylaxis during (mostly aspirin and low molecular weight heparin) and 1/4 of respondents (25%) commonly prescribe VTE prophylaxis after discharge (mostly aspirin). Of note, respectively 13% and 9% of participants observed at least one DVT and one PE related to right-sided ablation or EP study within the last year in their center. The present survey shows that only a minority of operators routinely gives intraprocedural intravenous heparin and prescribes VTE prophylaxis after right-sided EP procedures. Compared to left-sided procedures like atrial fibrillation (AF) ablation, there are no consistent systematic antithrombotic management strategies.

Provoked vs minimally provoked vs unprovoked VTE: does it matter?

Venous thromboembolism (VTE) is a multifactorial disease, and its risk depends on exposure to risk factors and predisposing conditions. Based on their strength of association with a VTE episode, risk factors are classified as major or minor and determined using a temporal pattern to be transient or persistent. All patients with VTE should receive anticoagulant treatment for at least 3 months in the absence of an absolute contraindication. Beyond this period, selected patients may be candidates for an extended phase of anticoagulation aimed at secondary VTE prevention. The risk of recurrent VTE if anticoagulation is discontinued is probably the main driver of decision-making regarding extended treatment. The risk of recurrence after VTE associated with major risk factors is low if the risk factor is no longer present. In this case, treatment can be discontinued. If the major risk factor is persistent, anticoagulation should be continued. After VTE occurring in the absence of risk factors, anticoagulation should probably be continued indefinitely if the risk for bleeding is low and preferably with minimal effective doses of anticoagulants. VTE occurring after exposure to minor risk factors is probably the most challenging situation, especially if the clinical manifestation was acute pulmonary embolism. Understanding the actual role of minor risk factors in the occurrence of VTE helps in estimating the risk of recurrence and avoiding the dangers associated with unnecessary anticoagulation. The availability of safer strategies for anticoagulation could allow personalized strategies for secondary prevention of VTE.

Effect of different application duration of a venous foot pump on prevention of venous thromboembolism after hip and knee arthroplasty: a multicenter prospective clinical trial

ObjectiveTo investigate the optimal duration of applying a venous foot pump (VFP) in the prevention of venous thromboembolism (VTE) following hip and knee arthroplasty.MethodsA total of 230 patients undergoing hip and knee arthroplasty between March 2021 and March 2022 in orthopaedic departments of four major teaching hospitals were prospectively enrolled. Patients were randomly divided into five groups based on the duration of the VFP application. Postoperative deep vein thromboses (DVT), including proximal, distal, and intermuscular DVT, were recorded for analysis. Postoperative blood coagulation examinations, such as D-dimer and active partial thromboplastin time (APTT), pain outcome, and degree of comfort were also collected.ResultsTwo of the 230 patients withdrew due to early discharge from the hospital, and 228 patients were included in the final analysis. The mean age was 60.38 ± 13.33 years. The baseline characteristics were comparable among the five groups. Compared with the other groups, patients treated with 6-hour VFP had the lowest incidence of DVT (8.7%, 4/46), followed by those treated with 1-hour VFP (15.2%, 7/46), 12-hour VFP (15.6%, 7/45), 18-hour VFP(17.8%, 8/45) and 20-hour VFP(21.7%, 10/46), but with no significant difference (P = 0.539). Regarding postoperative blood coagulation examinations, patients treated with 6-hour VFP had the lowest D-dimer (P = 0.658) and the highest APTT (P = 0.262) compared with the other four groups. 6-hour VFP also had the lowest pain score (P = 0.206) and the highest comfort score (P = 0.288) compared with the other four groups.ConclusionsSix hours may be the optimal duration of applying VFP for the prevention of VTE in patients undergoing hip and knee arthroplasty in terms of VTE incidence, postoperative blood coagulation examinations, pain outcomes, and comfort scores.

Developing the Form and Content of Implementation Strategies to Prevent Venous Thromboembolism for Ambulatory Patients with Cancer

Introduction To prevent venous thromboembolism (VTE) in people with cancer, guidelines recommend risk-assessment for those receiving systemic therapy and anticoagulation (AC) prophylaxis for those at high risk of VTE. However, these recommendations are significantly underused in clinical practice. Our prior work demonstrated barriers and facilitators contributing to this underuse and identified potential implementation strategies to address these barriers. The objective of this study was to develop the form and content of targeted implementation strategies promoting the uptake in clinical practice of guideline-recommendations for VTE prevention for ambulatory patients with cancer. Methods We conducted multidisciplinary stakeholder focus group discussions and semi-structured patient interviews to iteratively design the form and content of five implementation strategies (Table 1): (1) Conduct clinician education and training on risk-assessment models and anticoagulation thromboprophylaxis; (2) Adapt electronic health records (EHR) to provide interactive assistance; (3) Develop and distribute educational materials for clinicians about the Khorana score, VTE risk, and AC counseling; (4) Develop and distribute educational materials for patients; and (5) Audit and feedback. Stakeholders included oncologists, classical hematologists, an oncology clinical pharmacist, oncology advanced practice providers, and oncology patients, in academic and community-based settings within a single health care system. We conducted the clinician focus groups iteratively: in the first session we reviewed guidelines and evidence to support the use of risk assessment and AC prophylaxis in patients with cancer and shared barriers and facilitators identified in our earlier work. During subsequent sessions, we iteratively designed the form and content of the implementation strategies. In the final session, clinicians were presented a finalized prototype of the implementation strategies and asked to perform exploratory usability testing through simulated patient care encounters. Individual semi-structured interviews were conducted with patients to obtain feedback on the design of the implementation strategies and patient-education resources. Results A workflow for integration of risk-assessment and relevant prophylaxis in clinical practice was created based on participant feedback. Details for selected implementation strategies are shown in Table 1. For EHR support, stakeholders recommended the risk-assessment component be integrated within chemotherapy order sets. In addition, they recommended incorporating aid for AC management within the EHR, including a method to assess bleeding risk, pre-populated options for AC thromboprophylaxis, provision of easily accessible links to resources for peri-operative/procedure AC management, and a list of interactions between anticoagulants and common drugs used in oncology practice. Clinician stakeholders also recommended - and subsequently approved - standard phrases available to incorporate into the EHR documentation, both to guide decision-making and to serve as a reminder to re-assess in future visits. For education resources (clinician and patient), clinicians wanted education resources to be concise, and for the patient-facing resource, to be provided to patients both in existing “chemotherapy education” booklets and sent in after-visit appointment instructions. Regarding audit and feedback, clinicians recommended a personalized report card comparing their use of appropriate VTE prevention to their peers. After reviewing the patient-facing education documents, patients recommended simpler, straightforward language and clarifications for the VTE and AC patient education resources based on their past experiences. Conclusions With multidisciplinary stakeholder input from clinicians and patients, we developed a set of implementation strategies designed to address barriers to uptake of VTE prevention recommendations in oncology clinics. Next steps are to test the implementation strategies in clinical practice to measure impact on increasing these evidence-based interventions.