Prescription Of Venous Thromboembolism Prophylaxis Research Articles

The Use of Risk Scores for Thromboprophylaxis in Medically Ill Patients-Rationale and Design of the RICO trial.

Background Venous thromboembolism (VTE) in hospitalized medically ill patients is a significant cause of morbidity and mortality. Guidelines suggest that VTE and bleeding risk assessment models (RAMs) should be integrated into the clinical decision-making process on thromboprophylaxis. However, poor evidence is available comparing the use of a RAM versus clinical judgement in evaluating VTE and bleeding occurrence. Methods Reducing Important Clinical Outcomes in hospitalized medical ill patients (RICO) is a multicenter, cluster-randomized, controlled clinical trial (ClinicalTrials.gov Identifier: NCT04267718). Acutely ill patients hospitalized in Internal Medicine wards are randomized to the use of RAMs-namely the Padua Prediction Score and the International Medical Prevention Registry on Venous Thromboembolism Bleeding Score-or to clinical judgement. The primary study outcome is a composite of symptomatic objectively confirmed VTE and major bleeding at 90-day follow-up. Secondary endpoints include the evaluation of clinical outcomes at hospital discharge and the assessment of VTE prophylaxis prescription during the study period. In order to demonstrate a 50% reduction in the primary outcome in the experimental group and assuming an incidence of the primary outcome of 3.5% in the control group at 90-day; 2,844 patients across 32 centers will be included in the study. Discussion The RICO trial is a randomized study of clinical management assessing the role of RAMs in hospitalized medical ill patients with the aim of reducing VTE and bleeding occurrence. The study has the potential to improve clinical practice since VTE still represents an important cause of morbidity and mortality in this setting.

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

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

Analysis of Adherence to Thromboprophylaxis and Incidence of Venous Thromboembolism After Lower Limb Orthopaedic Surgery.

BackgroundThe economic burden caused by venous thromboembolism (VTE) to the National Health Service (NHS) is approximately £640 million. There is a significant national drive for VTE prophylaxis prescription given the high morbidity and mortality rates associated with VTE following lower limb orthopaedic surgery. The primary objective of this analysis was to examine the adherence to the updated VTE guidelines, NG89, by the National Institute for Health and Care Excellence (NICE) regarding prophylaxis for patients undergoing lower limb orthopaedic surgery, where the weight-bearing status will be reduced postoperatively, in an urban community hospital.MethodologyWe looked at 586 patients who underwent elective lower limb orthopaedic surgeries over a two year time period. We reviewed their VTE prophylaxis administration. Results were shared with the Hospital Thrombosis Committee department. Education was provided to the relevant staff and hospital policy for VTE prophylaxis. The primary endpoint was to compare the proportion of patients receiving prophylaxis as per the hospital guidelines as well as complications arising from VTE.ResultsA total of 586 patients were included in this audit. Compliance with VTE pharmacological prophylaxis was recorded, as well as weight-bearing status advised postoperatively. Compliance with prophylaxis in patients who were non-weight-bearing postoperatively was 54.8%. There were three cases of recorded VTE; however, in all cases, appropriate VTE prophylaxis has been prescribed.ConclusionIncreasing hospital-wide awareness and education of VTE and the fatal complications is imperative. All patients should be administered VTE prophylaxis as an inpatient and on discharge if their weight-bearing status is affected following lower limb orthopaedic surgery. Although our compliance rate for prescription of VTE prophylaxis did not achieve the standards set by NICE, all cases of recorded VTE had been correctly prescribed VTE prophylaxis on discharge.

Aspirin monotherapy is a suitable standard thromboprophylactic agent following total hip arthroplasty.

Aspirin is increasingly recognised as an efficacious thromboprophylactic agent with a superior safety profile compared to alternatives. Following our institution's previously published experience we implemented a risk-stratified protocol utilising aspirin as standard. We now present retrospective review of standard use of aspirin on fatal pulmonary embolism, all-cause mortality, and venous thromboembolism (VTE) following total hip arthroplasty (THA). A consecutive series of elective THAs was identified. Prospectively maintained databases were analysed to yield demographic data and identify deaths or readmission data. Patients who died within 90 postoperative days underwent review of the complete medical record. 4204 THAs were included in the study cohort. VTE prophylaxis prescription was available in 3805. 2560 received aspirin (67.3%), 1049 enoxaparin (27.6%) and 193 warfarin (5.1%); there were no differences in 90-day all-cause mortality (p = 0.780) or VTE (p = 1) between groups. Our large series continues to demonstrate that aspirin for thromboprophylaxis following THA is effective in risk-stratified patients. Furthermore, we demonstrate that introduction of a departmental protocol establishing aspirin as standard practice was not associated with increased mortality or incidence of thromboembolism. Taken in conjunction with our previous cohort our series encompasses 11,420 consecutive THAs. There has been a single death following fatal PE in the aspirin group (0.02%) compared to 5 in the LMWH group (0.2%) and 1 in the warfarin group (0.06%). We join calls for large-scale randomised controlled trials to elucidate the place of aspirin in VTE prevention following hip arthroplasty.

Multidisciplinary, patient-centred approach to improving compliance with venous thromboembolism (VTE) prophylaxis in a district general hospital

Hospital-acquired venous thromboembolism (VTE) accounts for an estimated 25 000 preventable deaths per annum in the UK and is associated with significant healthcare costs. The National Institute for Health and...

Inappropriate Venous Thromboembolism Prophylaxis in a General Surgery Department: Risk Factors and Improvement with a Simple Educational Program

The aim of this study was to describe the rate of patients with an inappropriate venous thromboembolism (VTE) prophylaxis in a Department of Surgery, study the risk factors associated with an inappropriate VTE prophylaxis, and analyze the effect of a simple educational program to improve these results. A quasi-experimental study was performed. VTE prophylaxis was studied in a Department of Surgery. The results of this analysis were presented to the Staff of the Department. Then, prophylaxis was again studied to analyze if this simple educational program improved these results. Inappropriate prophylaxis was seen in nearly 40% of the patients, mainly due to a lack of prescription. Inappropriate prophylaxis was associated with advanced age, ASA, surgical patient, no same-day surgery, no discharged patients, and high VTE risk. In the multivariate analysis, only no same-day surgery was related to inappropriate prophylaxis. The educational program achieved a non-significant reduction of inappropriate prophylaxis (31.7% vs. 40.5%, p = 0.070). A high percentage of patients in the Department of Surgery had an inappropriate VTE prophylaxis, mainly due to the lack of prescription. A simple educational program improved VTE prophylaxis prescription, although this improvement was not statistically significant.

Protocol implementation for venous thromboembolism prophylaxis: a before-and-after study in medical and surgical patients.

ABSTRACTObjectiveThis study aimed to assess the adequacy of venous thromboembolism (VTE) prophylaxis prescription after a protocol implementation.MethodsThis was a before-and-after study conducted in a tertiary care hospital in Rio Grande do Sul, Southern Brazil. Medical and surgical inpatients aged 18 years or older were assessed for VTE risk and subsequently for thromboprophylaxis adequacy, according to their risk. The evaluations occurred before and after the protocol strategy implementation; it consisted of an online platform to access the protocol, a public posting of the protocol diagram, clinical alerts on the medical staff TV, e-mail alerts, and pop-up alerts on the computerized physician order entry system. The main outcome measure was the adequacy of VTE prophylaxis prescription according to the protocol.ResultsA total of 429 patients were evaluated for thromboprophylaxis adequacy (213 before and 216 after). The prevalence of adequacy increased from 54% to 63% (pre and post-intervention, respectively), and after adjustment for patient type and phase of the study, the prevalence ratio reached (PR)=1.20, 95% confidence interval (CI) 1.02-1.42.ConclusionThe results showed that the overall appropriateness of thromboprophylaxis prescription was weakly improved. Despite these results, this study provides evidence to date a bunch of strategies for protocol implementations in private institutions in middle-income countries with an open medical staff, as there are few studies investigating these simple and pragmatic interventions.

Venous thromboembolism risk and prophylaxis prescription in surgical patients at a tertiary hospital in Eastern Cape Province, South Africa.

Venous thromboembolism (VTE) is a common complication during and after hospitalisation, and is regarded as the most common cause of preventable death in hospitalised patients worldwide. Despite its importance, there are few data on VTE risk and adherence to prophylaxis prescription guidelines in surgical patients from the South African (SA) public sector, especially from low-resource environments such as Eastern Cape Province. To evaluate the risk and prescription of VTE prophylaxis to surgical patients at a tertiary government hospital in the Eastern Cape. A cross-sectional clinical audit of general surgical inpatients was performed on two dates during July and August 2017. Patients' VTE risk was calculated by using the Caprini risk assessment model (RAM) and thromboprophylaxis prescription evaluated accordingly. A total of 179 patients were included in the study, of whom 56% were male and 44% female. The average age was 45 (range 18 - 83) years. Of the total number of participants, 33% were elective cases and 67% were emergency admissions. With application of RAM, 77% of patients were at risk of VTE (Caprini score ≥2), with 81% of elective and 74% of emergency patients being at risk. The most prevalent risk factors for VTE were major surgery (34%), age 41 - 60 years (30%), age 61 - 74 years (20%) and sepsis during the previous month (27%). A contraindication to chemoprophylaxis was recorded in 30% of patients, with the most prevalent being renal dysfunction (40%), peptic ulcer disease (34%), active bleeding (17%), liver dysfunction (17%), coagulopathy (6%) and recent cerebral haemorrhage (6%). With regard to VTE risk profile and contraindications to chemoprophylaxis, the correct thromboprophylactic treatment was prescribed to 26% of at-risk patients, with 21% of elective and 27% of emergency admission patients receiving the correct therapy. Despite a high proportion of patients being at risk of VTE, the rate of adequate thromboprophylaxis prescription for surgical inpatients at Frere Hospital, East London, SA is very low. Increased availability of mechanical prophylaxis, as well as interventions to improve the rate of adequate prophylaxis prescription, needs to be evaluated for feasibility and effect in this hospital and other SA public hospitals.

Improving Venous Thromboembolism Prophylaxis Administration in an Acute Surgical Unit.

Venous thromboembolism (VTE) prophylaxis regimes frequently have a wide variation in application. Nepean acute surgical unit was established in 2006 as a novel model for emergency surgical care. As part of the model's rollout, there were several areas of clinical management targeted for improvement, one being VTE prophylaxis compliance. It was decided all patients older than 18 years treated for a variety of acute surgical conditions within the acute surgical unit should be administered routine VTE prophylaxis with heparin and compression stockings. A novel multifaceted intervention was implemented at the time to achieve this goal. The primary aim of this study was to determine VTE prophylaxis administration rates before and after this intervention. A before-after study conducted as a retrospective review of medical records of all patients 18 years or older, having an appendicectomy in 3 periods: Before acute surgical unit (ASU) (November 2004 to October 2006), Early ASU (November 2006 to October 2008), and Established ASU (January 2012 to December 2013). Outcomes were mechanical and pharmacological VTE prophylaxis administration rates for each group. There were 1149 patients included in the study: Before ASU, 167; Early ASU, 375; and Established ASU, 607. There was a significant stepwise increase in parmacological VTE prophylaxis administration: Before ASU, 54.5%; Early ASU, 74.7%; and Established ASU, 96.9% (Before versus Early: odds ratio [OR], 2.46; 95% confidence interval [CI], 1.68-3.61; P < 0.001; Early versus Established: OR, 10.500; 95% CI, 6.29-17.53; P < 0.001). Mechanical VTE prophylaxis was significantly increased in the established group (Before versus Established: OR, 47.18; 95% CI, 25.61-86.91; P < 0.001). There was a significant increase in VTE prophylaxis administration after the implementation of our multifaceted intervention. Allocating a responsible provider dedicated to VTE prophylaxis prescription and compliance checking was a key component to this intervention.

VENOUS THROMBOEMBOLISM PROPHYLAXIS ON AN INPATIENT CARDIOLOGY WARD. WHO IS AT RISK OF UNDER TREATMENT?

Venous Thromboembolism (VTE) is a major cause of morbidity and mortality among hospitalized inpatients. However, the prescription of VTE prophylaxis remains suboptimal despite rigorous trials demonstrating its benefit and measures aimed at increasing compliance. There is a paucity of published data on the rates of VTE prophylaxis on cardiology inpatient wards. A paper previously published from our centre had demonstrated the short term beneficial effects of an electronic order protocol and educational campaign on decreasing the number of patients not treated with VTE prophylaxis from 36 to 26% in 5 months.

Individualized Performance Feedback to Surgical Residents Improves Appropriate Venous Thromboembolism Prophylaxis Prescription and Reduces Potentially Preventable VTE: A Prospective Cohort Study.

To investigate the effect of providing personal clinical effectiveness performance feedback to general surgery residents regarding prescription of appropriate venous thromboembolism (VTE) prophylaxis. Residents are frequently charged with prescribing medications for patients, including VTE prophylaxis, but rarely receive individual performance feedback regarding these practice habits. This prospective cohort study at the Johns Hopkins Hospital compared outcomes across 3 study periods: (1) baseline, (2) scorecard alone, and (3) scorecard plus coaching. All general surgery residents (n = 49) and surgical patients (n = 2420) for whom residents wrote admission orders during the first 9 months of the 2013-2014 academic year were included. Outcomes included the proportions of patients prescribed appropriate VTE prophylaxis, patients with preventable VTE, and residents prescribing appropriate VTE prophylaxis for every patient, and results from the Accreditation Council for Graduate Medical Education resident survey. At baseline, 89.4% of patients were prescribed appropriate VTE prophylaxis and only 45% of residents prescribed appropriate prophylaxis for every patient. During the scorecard period, appropriate VTE prophylaxis prescription significantly increased to 95.4% (P < 0.001). For the scorecard plus coaching period, significantly more residents prescribed appropriate prophylaxis for every patient (78% vs 45%, P = 0.0017). Preventable VTE was eliminated in both intervention periods (0% vs 0.35%, P = 0.046). After providing feedback, significantly more residents reported receiving data about practice habits on the Accreditation Council for Graduate Medical Education resident survey (87% vs 38%, P < 0.001). Providing personal clinical effectiveness feedback including data and peer-to-peer coaching improves resident performance, and results in a significant reduction in harm for patients.

Eliminating Health Care Disparities With Mandatory Clinical Decision Support: The Venous Thromboembolism (VTE) Example.

All hospitalized patients should be assessed for venous thromboembolism (VTE) risk factors and prescribed appropriate prophylaxis. To improve best-practice VTE prophylaxis prescription for all hospitalized patients, we implemented a mandatory computerized clinical decision support (CCDS) tool. The tool requires completion of checklists to evaluate VTE risk factors and contraindications to pharmacological prophylaxis, and then recommends the risk-appropriate VTE prophylaxis regimen. The objective of the study was to examine the effect of a quality improvement intervention on race-based and sex-based health care disparities across 2 distinct clinical services. This was a retrospective cohort study of a quality improvement intervention. The study included 1942 hospitalized medical patients and 1599 hospitalized adult trauma patients. In this study, the proportion of patients prescribed risk-appropriate, best-practice VTE prophylaxis was evaluated. Racial disparities existed in prescription of best-practice VTE prophylaxis in the preimplementation period between black and white patients on both the trauma (70.1% vs. 56.6%, P=0.025) and medicine (69.5% vs. 61.7%, P=0.015) services. After implementation of the CCDS tool, compliance improved for all patients, and disparities in best-practice prophylaxis prescription between black and white patients were eliminated on both services: trauma (84.5% vs. 85.5%, P=0.99) and medicine (91.8% vs. 88.0%, P=0.082). Similar findings were noted for sex disparities in the trauma cohort. Despite the fact that risk-appropriate prophylaxis should be prescribed equally to all hospitalized patients regardless of race and sex, practice varied widely before our quality improvement intervention. Our CCDS tool eliminated racial disparities in VTE prophylaxis prescription across 2 distinct clinical services. Health information technology approaches to care standardization are effective to eliminate health care disparities.

Thromboprophylaxis in nonsurgical patients.

Venous thromboembolism (VTE) is an important cause of preventable morbidity and mortality in medically ill patients. Randomized controlled trials indicate that pharmacologic prophylaxis reduces deep venous thrombosis (relative risk [RR] = 0.46; 95% confidence interval [CI], 0.36-0.59) and pulmonary embolism (RR = 0.49; 95% CI, 0.33-0.72) with a nonsignificant trend toward more bleeding (RR = 1.36; 95% CI, 0.80-2.33]. Low-molecular-weight heparin (LMWH) and unfractionated heparin are equally efficacious in preventing deep venous thrombosis (RR = 0.85; 95% CI, 0.69-1.06) and pulmonary embolism (RR = 1.05; 95% CI, 0.47-2.38), but LMWH is associated with significantly less major bleeding (RR = 0.45; 95% CI, 0.23-0.85). LMWH is favored for VTE prophylaxis in critically ill patients. New VTE and bleeding risk stratification tools offer the potential to improve the risk-benefit ratio for VTE prophylaxis in medically ill patients. Intermittent pneumatic compression devices should be used for VTE prophylaxis in patients with contraindications to pharmacologic prophylaxis. Graduated compression stockings should be used with caution. VTE prevention in medically ill patients using extended-duration VTE prophylaxis and new oral anticoagulants warrant further investigation. VTE prophylaxis prescription and administration rates are suboptimal and warrant multidisciplinary performance improvement strategies.

An observational study for venous thromboembolism risk assessment among hospitalized patients in general surgery clinics across Turkey

Venous thromboembolism (VTE) still remains a significant public health problem due to gaps between recommendations and clinical practice in VTE prophylaxis. This is the first clinical study designed to evaluate the applicability of a standard 'VTE prophylaxis and risk factor assessment form (VTE-PRAF)' and prescription of VTE prophylaxis among hospitalized patients in the daily practice of general surgeons in Turkey. A total of 1472 patients (mean age: 52.4 ± 16.9 years; 50.6% were men) were included in cross-sectional (n = 537), first longitudinal (n = 452) or the second longitudinal (n = 483) phases. Data on demographics, hospitalization, surgical intervention and prophylaxis were collected during the cross-sectional phase, whereas utilization of form was evaluated during longitudinal phases. While 62.1% of patients were identified to be at 'high+ highest' risk, prophylaxis was evident only for 65.9%. Utilization of the form was higher in the second longitudinal phase (P < 0.001) but there was no relation between implementation of the form and prophylaxis use. VTE-PRAF was completed for 70.6% and 84.8% of patient who received prophylaxis while it was completed for 50.8% and 50.4% of patients with no prophylaxis, in the first and second longitudinal phases, respectively. Prophylaxis was administered in 58.6% and 62.6% of patients with completed VTE-PRAF in the first and second longitudinal phases, respectively. 'Suggested' and 'used' prophylaxis regimens were significantly more consistent for the cases evaluated with VTE-PRAF (P < 0.001). Based on the use of prophylaxis only for 65.9% of general surgery inpatients at high risk for VTE, low use of prophylaxis is assumed to remain a significant threat to public health across Turkey. Inclusion of a standard VTE-PRAF in the hospital protocol seems to raise clinical awareness of VTE risk assessment and appropriate management in VTE which otherwise well-known to be associated with significant mortality and morbidity. Impact of e-VTE-PRAF is worth investigating.

Simple Multidisciplinary Education of Junior Doctors and Nurses Improves Prescription of Venous Thromboembolism Prophylaxis

Venous thromboembolism is the most common preventable cause of hospital death. Rates of thromboprophylaxis were studied prospectively in 158 surgical patients before and after multidisciplinary intervention. Prescription of mechanical prophylaxis improved from 58.8% to 76.6% (p = 0.015) following multidisciplinary education. Non-significant increases were seen in pharmacological prescription. Simple multidisciplinary education improves prescription of thromboprophylaxis. As postgraduate curricula for junior doctors and nurses evolve, we advocate routine inclusion of such sessions.

Efeito da implementação de diretriz para profilaxia de tromboembolismo venoso em pacientes cirúrgicos

Effective strategies for prevention of venous thromboembolism (VTE) are widely available, but still remain underused, mainly in our country. Our aim was to verify whether the implementation of a guideline for VTE prophylaxis for surgical patients influenced the prescription of prophylaxis by the medical staff. This was a retrospective preintervention-postintervention study. Charts of 150 patients before guideline implementation (BGI) and 150 after (AGI) were randomized among all patients admitted during one year in each period. >40 years-old, major abdominal or orthopedic surgeries. Incomplete files and use of anticoagulants for any reason at admission. Data registered: demographic data, reference to VTE risk factors, VTE prophylaxis prescription, diagnosis of deep venous thrombosis or pulmonary embolism during hospitalization. Results. The two groups, BGI and AGI were similar for demographic data and duration of prophylaxis (5.6 x 6.6 days). Frequency of prophylaxis in percentages was BGI x AGI respectively, before surgery: pharmacologic prophylaxis (PP), 6 x 9; graduated compression stockings (GCS), 4 x 3; intermittent pneumatic compression (IPC), 2 x 3. After surgery: PP, 53 x 53; GCS, 23 x 40 (P<0.05); IPC, 26 x 32. Including all patients, prophylaxis was prescribed for 60.5% BGI and 66.5% AGI, but was considered adequate only in 34% BGI and 32% AGI. Adoption of a guideline, although increasing concern about prophylaxis, expressed by greater use of GCS, only minimally improved quality of prophylaxis , indicating that other active and continuous interventions are necessary to enforce compliance.