Venous Thromboembolism Protocols Research Articles

An Effective Protocol for Perioperative Venous Thromboembolism Prophylaxis in DIEP Flap Breast Reconstruction: A Single Institution Retrospective Review.

Deep inferior epigastric artery perforator (DIEP) free flap breast reconstruction is one of the most highly used procedures for autologous breast reconstruction. Many venous thromboembolism (VTE) risk assessment models have been proposed in breast reconstructive surgery, including the widely used Caprini score. However, a paucity of data suggests an effective standardized VTE protocol. The purpose of this study was to determine the rate of VTE in our DIEP flap patients who were treated with this protocol. A retrospective single-center review of DIEP flap breast reconstruction from 2016 to 2021 was performed. Data were collected on 554 patients and 893 flaps including demographics, intraoperative and perioperative details, and postoperative course. Patients who were not treated with our standard protocol were excluded. Data were analyzed with alpha = 0.05. The average age was 50.4 ± 9.9 years, and the total follow-up time was 16.9 ± 12.6 months. The average body mass index for the cohort was 30.1 ± 5.2. During the 90 postoperative days, the mean length of hospital stay was 4.3 days. There were six cases of postoperative VTE: five patients presented with pulmonary embolism (0.9%) and one patient (0.2%) had deep venous thrombosis with an overall VTE prevalence of 1.1%. No specific single factor could be attributed to VTE occurrence. Using our standardized VTE prophylaxis protocol, our institution was effective at keeping VTE rates low. Additional studies would be beneficial to determine optimal VTE prophylaxis protocols in higher-risk patients, such as those with known clotting disorders.

Guidelines in Practice: Prevention of Venous Thromboembolism.

Venous thromboembolism (VTE), a condition involving deep vein thrombosis and embolism, can cause death when left untreated. Hospitalized patients and those who have recently undergone surgery or have a cancer diagnosis are at increased risk for VTE development. The updated AORN "Guideline for prevention of venous thromboembolism" provides perioperative nurses with a variety of evidence-based recommendations associated with the topic. This article provides an overview of the guideline and discusses recommendations for a VTE protocol, VTE and bleeding risk assessments, pharmacologic and mechanical VTE prophylaxis, postoperative ambulation, and patient and family education. It also includes a scenario that illustrates the importance of the VTE assessment and the use of mechanical prophylaxis for high-risk patients undergoing operative or other invasive procedures. Perioperative nurses should review the guideline in its entirety and implement recommendations in operative and procedural settings.

Venous Thromboembolism after DIEP Flap Breast Reconstruction: Review of Outcomes after a Postoperative Prophylaxis Protocol.

Deep inferior epigastric perforator (DIEP) flap breast reconstruction is among the higher-risk patient groups for venous thromboembolism (VTE) in plastic surgery. Surgeons often opt for a patient-specific approach to postoperative anticoagulation, and the field has yet to come to a consensus on VTE chemoprophylaxis regimens. A new chemoprophylaxis protocol was introduced starting in March of 2019 that involved 2 weeks of treatment with enoxaparin, regardless of patient risk factors. A retrospective chart review was conducted on all patients who underwent DIEP flap breast reconstruction at the authors' institution between January of 2014 and March of 2020. Patients were grouped based on whether they enrolled in the new VTE protocol in the postoperative period or not. Patient demographics, prophylaxis type, and outcomes data were recorded, retrospectively. The primary outcome measure was postoperative VTE incidence. Risk of VTE was significantly higher in patients discharged without VTE prophylaxis compared with patients discharged with prophylaxis (3.7% versus 0%; P = 0.03). Notably, zero patients in the VTE prophylaxis group developed a deep venous thrombosis or pulmonary embolism. In addition, the risk of a VTE event was 25 times greater in patients with a Caprini score greater than or equal to 6 ( P = 0.0002). The authors demonstrate the successful implementation of a 2-week VTE chemoprophylaxis protocol in DIEP flap breast reconstruction patients that significantly reduces the rate of VTE while not affecting the rate of hematoma complications. Therapeutic, III.

Venous Thromboembolism Prophylaxis in Pediatric Inflammatory Bowel Disease Patients Hospitalized With a Central Line.

Patients hospitalized with inflammatory bowel disease (IBD) have increased risk of venous thromboembolism (VTE). The aim of this study was to determine whether the adoption of a VTE protocol would change rates of medical VTE prophylaxis (low molecular weight heparin) in patients with IBD and a central venous catheter (CVC), while subsequently decreasing the incidence of VTE in this population. A protocol for VTE prophylaxis in IBD was established in March of 2018. Every patient hospitalized with an IBD flare and central venous access from March 2013 to March 2020 was identified. Study data, including patient demographics, rates of Doppler ultrasound (US), and rates of VTE were collected using International Classification of Diseases (ICD)-10 codes, CPT codes, and chart review retrospectively. Determination of an IBD flare was based on physician global assessment. Groups were compared with independent-sample t tests and chi-squared tests. A total of 313 hospitalizations across 187 different patients were identified that met criteria including IBD and central venous access. VTE prophylaxis increased from 5.24% (n = 12) prior to the intervention to 63.10% (n = 53) after the intervention [chi-square (1, N = 313) = 125.0192, P < 0.001]. Rate of Doppler US increased from 9.17% (n = 21) prior to the intervention to 17.86% (n = 15) after the intervention [chi-square (1, N = 313) = 4.5562, P < 0.05]. Diagnosis of VTE increased from 0.87% (n = 2) prior to the intervention to 7.14% (n = 6) after the intervention [chi-square (1, N = 313) = 9.6992, P < 0.01]. There were no significant differences in the demographic characteristics pre- versus post-intervention. Rates of Doppler US and VTE prophylaxis use increased significantly after implementation of a VTE protocol. Rates of VTE diagnosis also increased, though we suspect this may be due to missed diagnoses prior to implementation of the protocol and increased risk awareness after the protocol was established.

Comparing unfractionated heparin dose for VTE in obese versus non-obese patients

Background: Venous thromboembolism (VTE) is treated based on body weight to determine unfractionated heparin (UFH) dosage. However, this approach has not been thoroughly studied in obese patients. We aimed to determine the optimal infusion rate of UFH in obese patients using the weight-based dosing nomogram. Methods: A retrospective review was conducted on adult patients treated with heparin per VTE protocol with activated thromboplastin time (aPTT) of 60-80 seconds. We calculated the median heparin infusion rate (units/kg/hour) required to achieve the first therapeutic aPTT in obese and non-obese patients. We also investigated the median time required to achieve the first therapeutic aPTT in both groups, the percentage of aPTT at the target goal within the first 24 hours of treatment, the percentage of sub and supra-therapeutic aPTT at 24 hours after initiation of heparin infusion, and incidence of thrombosis and bleeding during heparin treatment. Results: We included 70 patients with confirmed VTE diagnosis. Obese patients required a lower UFH infusion rate (units/kg/hour) compared to non-obese patients (16.5 vs. 18, p = 0.24). The time to reach the first therapeutic aPTT was longer in obese patients compared to non-obese (17.7 hours vs. 15 hours respectively, p = 0.7). Major bleeding events were higher in the obese patients compared to the non-obese (6.25% vs. 2.6%, p = 0.44). In contrast, minor bleeding events were higher in the non-obese group (28.1% vs. 36.8%, p = 0.46). The overall rate of thrombotic events occurring during heparin treatment was 6.2% in obese patients and 5.3% in non-obese patients (p = 0.86). Conclusion: Dosing of UFH in obese patients using the weight-based nomogram was associated with over-anticoagulation and demonstrated no significant difference in UFH dosing to reach the goal of aPTT in obese or non-obese patients.

Promotion of a venous thromboembolism prevention protocol at a perioperative management center

Perioperative venous thromboembolism (VTE) is a potentially fatal complication, making preoperative VTE diagnosis and secondary thromboprophylaxis important. This study was performed to investigate the impact of promotion of a preoperative VTE protocol at a perioperative management center (PMC) on detecting the preoperative VTE rate and subsequent treatment. This retrospective study involved patients aged ≥20 years who underwent elective anesthesia. The patients were divided into two groups: the pre-PMC group (January to October 2014, before the opening of the PMC) and the post-PMC group (January to December 2019, after the opening of the PMC). The rates of preoperative lower-limb compression ultrasonography (CUS), VTE detection, anticoagulation therapy, and new postoperative pulmonary embolism (PE) were compared between the two groups. The pre-PMC and post-PMC groups comprised 3737 and 5388 patients, respectively. The preoperative CUS and VTE detection rates were significantly higher in the post-PMC than pre-PMC group (7.2% and 1.43% vs. 25.6% and 3.93%, respectively; P<0.001). There was no significant difference in the rate of anticoagulation therapy in patients with preoperative VTE (88.9% vs. 84.7%, P=0.43). Heparin and direct oral anticoagulants were primarily used in the pre-PMC and post-PMC groups, respectively. The efficacy and safety were comparable between the two groups. No new postoperative PE was detected in either group. Promotion of the preoperative VTE protocol led by the PMC increased the rates of preoperative CUS and preoperative VTE detection. This may aid in secondary thromboprophylaxis in the preoperative period and prevention of postoperative PE.

Venous Thromboembolism Prophylaxis Use by Pediatric Orthopedic Surgeons in Canada for the Pediatric Orthopedic Surgical Population.

Introduction A novel pediatric venous thromboembolism (VTE) screening tool was implemented in 2016 at the Izaak Walton Killam (IWK) Health Centre, which safely reduced the use of thromboprophylaxis by 47.9% with no increase in VTE in the pediatric orthopedic surgical population (POSP). There is presently no data on the current practices or protocols for VTE prophylaxis for POSP in Canada. The present survey was designed to assess current practices regarding VTE prophylaxis for POSP in Canada. Methods After research ethics board (REB) approval, a 22-question survey was administered electronically to all Canadian Pediatric Orthopedic Group (CPOG) members. The survey contained questions on respondent demographics and background, current VTE prophylaxis practices and experiences including indications for prophylaxis, the existence of VTE protocols, and interest in utilizing VTE protocols. Descriptive statistical analyses and analysis of variance (ANOVA) were completed on the survey responses. Results Of the 100 CPOG members, 49 (49%) responded. Most respondents (51%, n=25/49) practice in Central Canada, 39% (n=19/49) practice in Western Canadian provinces, and a smaller portion practice in Atlantic Canada (10%, n=5/49). Of the respondents,43% (n=21/49) indicated that they use pharmacologic VTE prophylaxis in their practice, and 93% (n=27/29) stated that specific risk factors are indications of initiating pharmacologic VTE prophylaxis. Additionally, 57% (n=16/28) did not have a defined protocol for VTE prophylaxis, and 18% (n=5/28) were uncertain if they do. Of the respondents, 85% (n=22/26) were open to utilizing a VTE prophylaxis screening tool, and 12% (n=3/26) were uncertain if they would be. Conclusion This study has demonstrated that a uniform protocol for VTE prophylaxis does not exist in most Canadian centers, despite its need. There is nationwide interest in adopting a perioperative VTE prophylaxis screening tool to optimize pharmacologic thromboprophylaxis use in POSP. The goal of future research is the national implementation and standardization of such a screening tool through collaboration in a multicenter study.

Estimating incidence of venous thromboembolism in COVID‐19: Methodological considerations

BackgroundCoagulation abnormalities and coagulopathy are recognized as consequences of severe acute respiratory syndrome coronavirus 2 infection and the resulting coronavirus disease 2019 (COVID‐19). Specifically, venous thromboembolism (VTE) has been reported as a frequent complication. By May 27, 2021, at least 93 original studies and 25 meta‐analyses investigating VTE incidence in patients with COVID‐19 had been published, showing large heterogeneity in reported VTE incidence ranging from 0% to 85%. This large variation complicates interpretation of individual study results as well as comparisons across studies, for example, to investigate changes in incidence over time, compare subgroups, and perform meta‐analyses. ObjectivesThis study sets out to provide an overview of sources of heterogeneity in VTE incidence studies in patients with COVID‐19, illustrated using examples. MethodsThe original studies of three meta‐analyses were screened and a list of sources of heterogeneity that may explain observed heterogeneity across studies was composed. ResultsThe sources of heterogeneity in VTE incidence were classified as clinical sources and methodologic sources. Clinical sources of heterogeneity include differences between studies regarding patient characteristics that affect baseline VTE risk and protocols used for VTE testing. Methodologic sources of heterogeneity include differences in VTE inclusion types, data quality, and the methods used for data analysis. ConclusionsTo appreciate reported estimates of VTE incidence in patients with COVID‐19 in relation to its etiology, prevention, and treatment, researchers should unambiguously report about possible clinical and methodological sources of heterogeneity in those estimates. This article provides suggestions for that.

Evaluation of risk stratification and adherence to venous thromboembolism prophylaxis among hospitalized obstetric women: Retrospective case file review at East Jeddah Hospital during 2018-2019.

BACKGROUND:Venous thromboembolism (VTE) is associated with substantial mortality as well as morbidity and is largely preventable among hospitalized obstetric women. However, thromboprophylaxis is underutilized in most hospitalized patients.OBJECTIVES:To evaluate VTE risk and adherence to local thromboprophylaxis protocol among hospitalized pre- and postnatal women.METHODS:This retrospective study was conducted at East Jeddah Hospital, Jeddah, Saudi Arabia, in 2020. The electronic record database of the hospitalized pregnant Saudi women during the years 2018 and 2019 was reviewed. Based on the local hospital protocol, the risk stratification was reassessed by researchers, and the hospital adherence to the prophylaxis was reviewed separately for antenatal and postnatal women.RESULTS:One thousand and ninety-five electronic records (539 antenatal and 556 postnatal) were reviewed. The postnatal group showed a significantly higher risk compared with an antenatal group (62.2% vs. 11.7%) (P = 0.000). There was a highly significant difference between risk categories assessment by the physicians and the researchers in both groups (P = 0.000). Thromboprophylaxis was overutilized in the low risk (5% heparin and 41.4% heparin and mechanical devices for antenatal and 17.08% heparin and 6.1% heparin and a mechanical device for the postnatal group) and underutilized in intermediate groups (50% no prophylaxis in antenatal and 51.5% mechanical devices in the postnatal group). There was less adherence to documentation in postnatal as compared to antenatal group (83.6% vs. 95%, P = 0.000) for risk documentation and 85.3% versus 91.5% for physician signature (P = 0.001). Thromboprophylaxis was ordered for 21.3% of antenatal (12.2 heparin, 3.5% mechanical, and 5.6% both) and 23.7% of postnatal patients (16.5 heparin, 2% mechanical, and 5.2% both). There were no reported VTE events or bleeding complications.CONCLUSION:There was a considerable VTE risk among hospitalized obstetric patients which peaked during the postnatal period. Physicians showed good compliance to local VTE protocol with no reported VTE events or drug-induced bleeding. However, the implementation of prophylaxis is associated with both under and overutilization. There is a need for increasing the physicians’ awareness of optimizing VTE risk assessment and documentation for hospitalized obstetric patients.

Post-operative oral chemoprophylaxis in patients undergoing hip arthroscopy mitigates VTE risk with a low side-effect profile.

Hip arthroscopy (HA) has increased exponentially over the last decade. A recent systematic review found that the risk of venous thromboembolism (VTE) is 2%. This was higher than previous reports which may have underestimated the true incidence of VTE in HA. Thus, protocols to mediate VTE may be more necessary than previously thought. The aim of this article is to present a VTE prevention protocol and evaluate its subsequent efficacy. This is a prospective study of 880 consecutive HA cases. All patients were treated according to a predetermined VTE protocol which classified patients as high (≥1 risk factors) or low (no risk factors) risk for post-operative VTE. In high-risk patients, the protocol followed that of low-risk patients but additionally included rivaroxaban for 2 weeks post-operatively. The incidence of VTE was recorded and analysed in this study. A total of 880 HA cases at an average age of 35.4 years were evaluated, with 76.6% (n = 674) undergoing labral repair and concomitant cam and/or pincer resection, 17.2% (n = 151) of cases for isolated labral tear repaired, and 6.1% (n = 55) classified as other. The overall incidence of VTE was 0.45%. The incidence of VTE was 1.2% and 0.16% in high- and low-risk groups, respectively. Oral VTE prophylaxis was not associated with post-operative complications. This study demonstrated a lower rate of VTE in both risk groups. It highlights the value of a predetermined risk-adjusted protocol to VTE prophylaxis. Rivaroxaban prophylaxis is safe and efficacious in HA with a low associated morbidity.

Venous thromboembolism in the emergency department: A survey of current best practice awareness in physicians and nurses in China.

For emergency department (ED) patients, risk assessment, prophylaxis, early diagnosis and appropriate treatment of venous thromboembolism (VTE) are essential for preventing morbidity and mortality. This study aimes to investigate knowledge amongst emergency medical staff in the management of VTE. We designed a questionnaire based on multiple scales. The questionnaire was distributed to the medical and nursing clinical staff in the large urban ED of a medical center in Northern China. Data was described with percentages and the Kruskal-Wallis test was used to compare ranked data between different groups. The statistical analysis was done using the SPSS 22.0 software. In this survey, 180 questionnaires were distributed and 174 valid responses (response rate of 96.67%) were collected and analyzed. In scores of VTE knowledge, no significant differences were found with respect to job (doctor vs. nurse), the number of years working in clinical medicine, education level, and current position, previous hospital experience and nurses' current work location within the ED. However, in pair wise comparison, we found participants who worked in ED for more than 5 years (n=83) scored significantly higher on the questionnaire than those under 5 years (n=91) (95.75 vs. 79.97, P=0.039). There was a significant difference in some questions based on gender, age, job, and nurse work location, number of working years, education level, and different ED working lifetime. Our survey has shown deficiencies among ED medical staff in knowledge and awareness of the management of VTE. We recommend several changes be considered, such as the introduction of an interdisciplinary workshop for medical staff; the introduction of a standardized VTE protocol; a mandatory study module on VTE for new physicians and nurses; the introduction of a mandatory reporting system for adverse events (including VTE).

PS02.216: PROPHYLAXIS OF POSTOPERATIVE VENOUS THROMBOEMBOLISM USING ENOXAPARIN AFTER ESOPHAGECTOMY: A PROSPECTIVE OBSERVATIONAL STUDY FOR EFFECTIVENESS AND SAFETY

Abstract Background Incidence of venous thromboembolism (VTE) after esophagectomy is higher than those in other gastroenterological cancer surgery. However, the strategy of thromboprophylaxis during esophagectomy has not been established. Although effectiveness and safety of thromboprophylaxis using enoxaparin have been established in orthopedic, abdominal, and pelvic surgeries, no studies are available regarding esophagectomy. Methods We conducted a prospective observational study to elucidate the usefulness of enoxaparin to prophylactic VTE after esophagectomy. Thirty patients who underwent elective three-incision esophagectomy for esophageal cancer between April 2015 and October 2016 were enrolled. During the postoperative day (POD) 2 to 11, patients received a subcutaneous injection of enoxaparin (2000 IU) twice daily. The primary endpoint was the incidence of postoperative VTE. In addition, the incidence of all enoxaparin treatment-related and operation-related adverse events were also investigated. VTE was identified by VTE protocol enhanced CT, which was routinely performed during enoxaparin treatment and after enoxaparin treatment. Results One pulmonary embolism (PE) (3.3%) and 2 deep vein thrombosis (DVT) (6.7%) were observed during enoxaparin treatment. In addition, further one PE (3.6%) and 4 DVTs (14.3%) (one patient suffered the both) were observed after treatment. All VTEs were asymptomatic. Regarding enoxaparin-related adverse events, 4 minor bleedings without a need of stopping enoxaparin occurred. Incidence of postoperative morbidity was acceptable. In blood tests related to coagulation system, no significant differences were observed between patients with and without VTE. Conclusion We believe that thromboprophylaxis using enoxaparin is safe and can prevent VTE after esophagectomy. However, the effectiveness is limited in the period of treatment, additional prophylaxis following enoxaparin treatment may be recommended. Disclosure All authors have declared no conflicts of interest.

Initiating a Standard Venous Thromboembolism Prophylaxis Order Set Designed to Improve Patient Outcomes at Los Angeles County + University of Southern California

Improving patient safety is vital for all hospitals due to increasing public reporting and pay-for-performance reimbursement. Venous thromboembolism (VTE) remains a leading cause of preventable mortality accounting for 5 per cent of inpatient deaths. The purpose of this study was to outline the process of implementing standard VTE prophylactic order sets in a 600-bed academic safety net hospital and assess the resulting change in patient outcomes. Outcomes were assessed by comparing the rate that eligible inpatients receive VTE prophylaxis and the rate of preventable VTE's compared with total VTE's. From 2011 to 2015, random samples of 60 Los Angeles County+University of Southern California inpatients were generated monthly to examine compliance rates by comparing ICD-9 diagnostic codes to ordered VTE prophylaxis. All inpatient VTE's are retrospectively analyzed. Baseline-ordered VTE prophylaxis was 37 per cent in 2010. The target of 85 per cent was exceeded by the second quarter of 2012 to 2013 when compliance reached 88 per cent, a 51 per cent increase from baseline (P < 0.01). These results suggest VTE protocols are effective though standardization across service lines is often difficult. Despite these challenges, after implementing standard order sets, we saw compliance increase significantly. Ongoing analysis to determine whether VTE rates have significantly decreased is presently underway.

A Clinical Tool for the Prediction of Venous Thromboembolism in Pediatric Trauma Patients.

Although rare, the incidence of venous thromboembolism (VTE) in pediatric trauma patients is increasing, and the consequences of VTE in children are significant. Studies have demonstrated increasing VTE risk in older pediatric trauma patients and improved VTE rates with institutional interventions. While national evidence-based guidelines for VTE screening and prevention are in place for adults, none exist for pediatric patients, to our knowledge. To develop a risk prediction calculator for VTE in children admitted to the hospital after traumatic injury to assist efforts in developing screening and prophylaxis guidelines for this population. Retrospective review of 536,423 pediatric patients 0 to 17 years old using the National Trauma Data Bank from January 1, 2007, to December 31, 2012. Five mixed-effects logistic regression models of varying complexity were fit on a training data set. Model validity was determined by comparison of the area under the receiver operating characteristic curve (AUROC) for the training and validation data sets from the original model fit. A clinical tool to predict the risk of VTE based on individual patient clinical characteristics was developed from the optimal model. Diagnosis of VTE during hospital admission. Venous thromboembolism was diagnosed in 1141 of 536,423 children (overall rate, 0.2%). The AUROCs in the training data set were high (range, 0.873-0.946) for each model, with minimal AUROC attenuation in the validation data set. A prediction tool was developed from a model that achieved a balance of high performance (AUROCs, 0.945 and 0.932 in the training and validation data sets, respectively; P = .048) and parsimony. Points are assigned to each variable considered (Glasgow Coma Scale score, age, sex, intensive care unit admission, intubation, transfusion of blood products, central venous catheter placement, presence of pelvic or lower extremity fractures, and major surgery), and the points total is converted to a VTE risk score. The predicted risk of VTE ranged from 0.0% to 14.4%. We developed a simple clinical tool to predict the risk of developing VTE in pediatric trauma patients. It is based on a model created using a large national database and was internally validated. The clinical tool requires external validation but provides an initial step toward the development of the specific VTE protocols for pediatric trauma patients.

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Introduction: Although venous thromboembolism (VTE) risk factors for pediatric trauma patients have been identified in recent literature, overall low occurrence rates have resulted in minimal guidance on risk assessments and prophylaxis regimens. Methods: A single center retrospective chart review of patients 17 years of age and younger admitted to the Pediatric Trauma Service between July 1, 2008 and December 1, 2011 was conducted. A VTE risk assessment was developed and retrospectively applied to each patient to determine appropriateness of VTE prophylaxis. Results: Eight hundred four patients met initial inclusion criteria. Of these, 200 were evaluated with the VTE risk assessment and included for review. The median age was 11 years (IQR 5–16). One hundred twenty-five patients (62%) received appropriate prophylaxis. Reasons for inappropriate prophylaxis were a lack of sequential compression device (SCD) orders in 55 patients (73%), lack of pharmacologic prophylaxis orders in 14 patients (19%), and pharmacologic prophylaxis orders when not indicated by the risk assessment in six patients (8%). Pharmacologic prophylaxis was prescribed in 28% of patients. VTE occurred in four patients. Risk factors for VTE were an elevated Injury Severity score (p=0.03), lower Glasgow Coma Scale score (p=0.03), and the presence of central venous lines (p=0.004). Median ICU length of stay for patients with and without a VTE was nine (IQR 7–45) vs two days (IQR 0–4), respectively (p=0.006). Median hospital length of stay was 25 (IQR 14–51) vs six days (IQR 4–11), respectively (p=0.008). One bleeding event occurred (0.5%) in a patient receiving treatment dose anticoagulation. There was one death unrelated to VTE events. Conclusions: Though VTE prophylaxis is commonly administered to pediatric patients at this trauma center, adherence (62%) has room for improvement according to the study VTE risk assessment and recommendations. A standard VTE risk assessment and protocol may be beneficial in this population to ensure consistent prophylaxis.

Is extended thromboprophylaxis necessary in elective colorectal cancer surgery?

Colorectal cancer surgery carries a high risk of venous thromboembolism (VTE) but the optimal duration of thromboprophylaxis is unknown. The cost-effectiveness of extended prophylaxis is not known in Australasia. The aims of this study were to determine the 30-day incidence of VTE in patients undergoing colorectal cancer surgery, to audit compliance with thromboprophylaxis protocols and to estimate the cost of treating all patients for 28 days with enoxaparin. Patients undergoing elective colorectal cancer surgery from 2007 to 2009 at the Royal Adelaide and Queen Elizabeth hospitals were identified from a prospective database. Case note review was conducted for patient demographics, VTE risk factors, types of thromboprophylaxis used, complications, readmission rate and VTE rate. Documented compliance with unit VTE protocols was calculated. The cost of treating all patients with enoxaparin as prophylaxis for 28 days was then estimated. A total of 254 patients were identified. The in-hospital VTE rate was 0.79% (2 out of 254). The post-discharge VTE rate was 0.39% (1 out of 254). Compliance with thromboprophylaxis protocols was excellent. Pharmacological thromboprophylaxis was used in 97% of patients, graduated compression stockings in 84% and pneumatic compression devices in 53%. The estimated cost of extended prophylaxis for all 254 patients was $32,308.80. We have demonstrated excellent compliance with in-hospital thromboprophylaxis. Hence, we have low VTE rates in-particular, post-discharge VTE. The infrequency of post-discharge VTE means that the cost-effectiveness of extended prophylaxis might be questioned.

Improving VTE prophylaxis in hospitalized oncologic patients: Institutional impact VTE mentored QI project.

148 Background: Venous thromboembolism (VTE), which includes deep vein thrombosis and pulmonary embolism affects hundreds of thousand Americans each year. Pulmonary embolism(PE), is the 3rd leading cause of hospital related death and the most common preventable cause of death in the United States. Cancer is associated with 6-fold increase in the risk of VTE. For those undergoing surgery, the risks of post-operative DVT and fatal PE are 2-3 times greater, respectively, for cancer patients than non-cancer patients. VTE prophylaxis is widely available and effective, but frequently underused. VTE prevention is of particular concern to oncologists. Evidence based oncology-specific guidelines are available from several organizations including American Society of Clinical Oncology (ASCO) to highlight the importance of prophylaxis in oncology patients. An Interdisciplinary team of pharmacists and hospitalists received an educational grant to implement a VTE mentored project in a large Comprehensive Academic Cancer Center in the Southern United States. There was anecdotal evidence and data to suggest adherence to thrombo-prophylaxis was suboptimal, with multiple departments and physicians having their "own" order sets of varying complexities. Performance data on VTE was not routinely being collected and data on hospital-acquired VTE events was not consistently collected and reported. To meet increasing financial, regulatory and the clinical challenge of harmonizing VTE prophylaxis in the institution, a multi-disciplinary team was formed to implement this VTE initiative. Methods: The QI methodology used was the Plan, Do, Study and Act (PDSA). Step 1. Draft a single VTE protocol using best evidence with input from all stakeholders that will be acceptable to most users. Step 2. Analyze the care delivery throughout the hospital Step 3. Set up performance tracking with IT support Step 4. Staggered introduction/education of the VTE protocol across departments/physicians Step 5. Implement and track through cycles of PDSA. Results: The institution went from having about 10 different VTE order sets to a single VTE order set that was a single page and was utilized by medical, surgical and emergency room and ICU physicians. This was embed in all admission, transfer and post op orders. Use of VTE prophylaxis order set went from an aggregate of 40.7 to 76.1%, 3 months after implementation of initiative. 26% percent of patient with no prophylaxis ordered had no contraindications checked. 60.9% and 16% of admitted patients were risk stratified as moderate or high risk respectively. Conclusions: 4 key findings from the implementation project led to improved rates of thrombo-prophylaxis. Prescribers are in the best position to understand all components of the VTE risk as well as contraindications and should be responsible for VTE risk assessment, as hitherto nurses were doing risk assessment and physicians were prescribing prophylaxis. New VTE order set provided a linked menu of appropriate prophylaxis options for each level of risk which the older sets did not do. Embedding VTE order set in admission/transfer and post op orders sets led to increase use. Efforts to raise VTE awareness should be ongoing, routinely monitored and included with other safety indicators such as falls etc and reported back to providers and appropriate medical staff and executive committees.

Performance measures for improving the prevention of venous thromboembolism: achievement in clinical practice

Venous thromboembolism (VTE) is a common complication during and after hospitalization for acute medical illness or surgery. Despite the existence of evidence-based guidelines for VTE prevention, real-world prescribing practices are frequently suboptimal. Specific performance measures relating to VTE prevention and treatment have been developed by US health care organizations to increase adherence with best-practice recommendations and ultimately reduce the number of preventable VTE events. Two measures developed by the Surgical Care Improvement Project have been endorsed by the National Quality Forum (NQF) and focus on VTE prevention. In addition, six measures have been developed recently by The Joint Commission in collaboration with the NQF; three measures relate to VTE prevention and three focus on treatment. To attain widespread achievement of these performance goals, it is essential to raise awareness of their existence and specifications. It is also imperative that hospitals develop and implement effective VTE protocols. The use of multiple, active strategies, such as computer decision support systems with regular audit and feedback, may be particularly valuable approaches to improve current practices within an integrated quality improvement program. During practical implementation of VTE protocols at Norton Healthcare (Kentucky's largest healthcare system), strong leadership, physician engagement, and caregiver accountability were identified as key factors influencing the process. As such, more hospitals may be able to increase adherence with guidelines, improve achievement of quality goals, and help to reduce the substantial burden associated with avoidable VTE.

Venous Thromboembolism Prophylaxis in Surgical Patients: Identifying a Patient Group to Maximize Performance Improvement

Venous thromboembolism (VTE) in surgical patients is a cause of increased morbidity, mortality, and cost of care. Deep vein thrombosis (DVT) prophylaxis reduces the risk of DVT or pulmonary embolism (PE), but not to zero, which is concerning because DVT/PE is being considered a serious reportable event. A study was conducted in January-June 2009 to test the hypothesis that most surgical VTEs occur despite the patient's receiving appropriate prophylaxis. All patients with a surgical diagnosis-related group (DRG) who had a documented DVT/PE in 2008 were retrospectively reviewed. Each VTE episode was characterized as occurring during the index admission for surgery or being present on admission (POA). DVT prophylaxis compliance was measured in all patients who had a procedure at the institution, a 454-bed university teaching hospital, and those patients were classified in terms of compliance with our VTE protocols. Class 1 patients had VTE protocols followed; Class 2 patients had contraindications to VTE protocols documented; Class 3 patients should have received VTE prophylaxis but did not; and Class 4 patients had contraindications to VTE prophylaxis that were not documented. Some 156 (6.3%) of 2,474 surgical patients had a DVT/PE in 2008; for the 144 patients with complete records for review, 89 were candidates for VTE prophylaxis. Some 77 of the 89 patients had received appropriate VTE prophylaxis or had documented contraindications to prophylaxis. Eleven (12.4%) patients who should have received VTE prophylaxis did not. Compliance with VTE protocols continues to be less than 100%, and even when patients adhere to existing protocols VTE events continue to occur.

Venous Thromboembolic Events in the Rehabilitation Setting

Abstract Venous thromboembolism (VTE) is a disease entity that encompasses both deep venous thrombosis and pulmonary embolism. During the past decade there have been significant advances in the understanding of prophylaxis and treatment of VTE. There is an extensive research base from which conclusions can be drawn, but the heterogeneity within the rehabilitation patient population makes the development of rigid VTE protocols challenging and overwhelming for the busy clinician. Given the prevalence of this condition and its associated morbidity and mortality, we review the evidence for the prevention, identification, and optimal treatment of VTE in the rehabilitation population. Our goal is to highlight studies that have the most clinical applicability for the care of VTE patients from a physiatrist's perspective. At times, information about acute care protocols is included in our discussion because these situations are encountered during the consultation process that identifies patients for rehabilitation needs.