Multi-screen electronic alerts to augment venous thromboembolism prophylaxis

2010 ◽  
Vol 103 (02) ◽  
pp. 312-317 ◽  
Author(s):  
Karen Fiumara ◽  
Chiara Piovella ◽  
Shelley Hurwitz ◽  
Gregory Piazza ◽  
Clyde Niles ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
High Risk ◽  
Thromboembolism Prophylaxis ◽  
Vte Prophylaxis ◽  
Hospitalised Patients ◽  
Electronic Alerts ◽  
Significant Difference ◽  
Alert Program ◽  
Risk Patients ◽  
The One

SummaryVenous thromboembolism (VTE) prophylaxis in high-risk patients is frequently underutilised. We previously devised a one-screen computer alert program that identified hospitalised patients at high risk for VTE who were not receiving prophylaxis and advised their physicians to prescribe prophylaxis. While this strategy reduced the 90-day incidence of symptomatic VTE by 41%, the majority of electronic alerts were ignored. We have now developed a serial three-screen alert computer program designed to educate physicians who initially declined to order prophylaxis after a single screen alert. Of a total cohort of 880, the responsible physicians for 425 patients received a single electronic alert, whereas 455 who declined prophylaxis after the first screen received the second and third screens of the novel three-screen alert. Our enhanced serial three-screen alert program generated VTE prophylaxis orders for 58.4% of the 455 patients whose physicians initially declined to order prophylaxis following the one-screen alert. There was no significant difference in symptomatic 90-day VTE rates between the two cohorts (2.8% for the one-screen vs. 2.2% for the three-screen, p=0.55). We conclude that our three-screen computer alert program can markedly increase prophylaxis among physicians who decline an initial single screen alert.

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

2020 ◽  
Vol 16 (9) ◽  
pp. e868-e874 ◽  
Author(s):  
Chris E. Holmes ◽  
Steven Ades ◽  
Susan Gilchrist ◽  
Daniel Douce ◽  
Karen Libby ◽  
...  
Keyword(s):  
Risk Assessment ◽  
Venous Thromboembolism ◽  
High Risk ◽  
Assessment Tool ◽  
Guideline Implementation ◽  
Vte Prophylaxis ◽  
Successful Model ◽  
Venous Thromboembolism Prevention ◽  
Risk Patients ◽  
Cancer Associated Thrombosis

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

scholarly journals Prophylaxis of venous thromboembolism in general surgery: guidelines differ and we still need local policies

2011 ◽  
Vol 93 (5) ◽  
pp. 370-374
Author(s):  
D Veeramootoo ◽  
L Harrower ◽  
R Saunders ◽  
D Robinson ◽  
WB Campbell
Keyword(s):  
At Risk ◽  
Venous Thromboembolism ◽  
High Risk ◽  
Risk Groups ◽  
Low Risk ◽  
Vte Prophylaxis ◽  
Risk Patients ◽  
Local Policies ◽  
One Year ◽  
The Uk

INTRODUCTION Venous thromboembolism (VTE) prophylaxis has become a major issue for surgeons both in the UK and worldwide. Sev-eral different sources of guidance on VTE prophylaxis are available but these differ in design and detail. METHODS Two similar audits were performed, one year apart, on the VTE prophylaxis prescribed for all general surgical inpatients during a single week (90 patients and 101 patients). Classification of patients into different risk groups and compliance in prescribing prophylaxis were examined using different international, national and local guidelines. RESULTS There were significant differences between the numbers of patients in high, moderate and low-risk groups according to the different guidelines. When groups were combined to indicate simply ‘at risk’ or ‘not at risk’ (in the manner of one of the guidelines), then differences were not significant. Our compliance improved from the first audit to the second. Patients at high risk received VTE prophylaxis according to guidance more consistently than those at low risk. CONCLUSIONS Differences in guidance on VTE prophylaxis can affect compliance significantly when auditing practice, depending on the choice of ‘gold standard’. National guidance does not remove the need for clear and detailed local policies. Making decisions about policies for lower-risk patients can be more difficult than for those at high risk.

Post-discharge venous thromboembolism prophylaxis for surgical oncology patients.

2017 ◽  
Vol 35 (8_suppl) ◽  
pp. 79-79
Author(s):  
Ashlie Nadler ◽  
Mary Ellen Morba ◽  
Jesse Pezzella ◽  
Jeffrey M. Farma
Keyword(s):  
Venous Thromboembolism ◽  
High Risk ◽  
Compliance Rate ◽  
Surgical Oncology ◽  
Pelvic Surgery ◽  
Cancer Center ◽  
Thromboembolism Prophylaxis ◽  
Post Discharge ◽  
Oncology Patients ◽  
Vte Prophylaxis

79 Background: A number of guidelines have been proposed for prolonged venous thromboembolism (VTE) prophylaxis following hospital discharge for cancer patients undergoing major abdominal or pelvic surgery. However, there is disparity in how closely these guidelines are followed. The purpose of this study was to examine the administration and complications of post-discharge chemical VTE prophylaxis (pdVTE) at an institutional level among surgical oncology patients to help inform policy creation. Methods: A retrospective study at a tertiary referral cancer center was performed. Data was analyzed for patients undergoing surgery in 2015. Chi-square tests were performed. Results: Of 566 colorectal, urologic, and gynecologic surgical oncology procedures performed in 2015, 24% (137) were discharged with a prescription for enoxaparin for pdVTE. An additional 24 patients were already on another form of anticoagulation at the time of discharge. Of the patients discharged on pdVTE, 77% (105) had the prescriptions filled. The compliance rate of those patients was 96% (101). The rate of VTE was 3.5% for all patients. There was a significantly greater rate of VTE amongst patients that received pdVTE (10.4%) compared to those who did not (1.6%) (OR 7.20, CI 2.80-18.46, p < 0.001). For each subspecialty, there was also a significantly greater rate of VTE amongst patients that received pdVTE (p < 0.001). Conclusions: There is a very low rate of pdVTE administration despite current guidelines. Identifying patients who received pdVTE appears to identify patients at high risk for VTE rather than the benefits of pdVTE. Institutional policies regarding prolonged VTE prophylaxis should be implemented to target high-risk patients and to ensure appropriate prescribing practices. [Table: see text]

Combined modalities in the prevention of venous thromboembolism: A review of the literature

2006 ◽  
Vol 21 (1_suppl) ◽  
pp. 23-28 ◽  
Author(s):  
S K Kakkos ◽  
J A Caprini ◽  
A N Nicolaides ◽  
D Reddy
Keyword(s):  
Venous Thromboembolism ◽  
High Risk ◽  
Risk Groups ◽  
Intermittent Pneumatic Compression ◽  
Low Molecular Weight ◽  
Review Of The Literature ◽  
Case Control Studies ◽  
Vte Prophylaxis ◽  
Risk Patients ◽  
Elastic Stockings

Objective Despite recent advances in the field of venous thromboembolism (VTE) prophylaxis and adherence to guideline recommendations, VTE remains a serious problem, especially in high-risk groups. The aim of the present review was to summarize the evidence supporting the use of combined modalities, both physical and pharmacological, in VTE prevention. Methods Using Medline, original studies on the value of combined modalities in VTE prevention were identified. Keywords used for physical methods included elastic stockings and intermittent pneumatic compression, and for pharmacological methods included unfractionated and low molecular weight heparin. Relevant articles from their bibliography were also retrieved. Results Combined pharmacological and physical modalities were more effective than each modality alone in a variety of specialties, including orthopaedic, general and cardiac surgery, as shown by 14 of the 18 randomized or case-control studies retrieved. Mean reduction in VTE incidence was 69% (range 16–100%). Conclusion Combined modalities are more effective than single modalities in VTE prophylaxis. These results endorse their use, especially in high-risk patients, and support this otherwise typical recommendation of the consensus documents on VTE prophylaxis.

scholarly journals Retrospective Study of Venous Thromboembolism Prophylaxis Dosing of Heparin in Adult Patients receiving Continuous Renal Replacement Therapy

2021 ◽  
Vol 6 (2) ◽  
Keyword(s):  
Venous Thromboembolism ◽  
Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Thromboembolism Prophylaxis ◽  
Vte Prophylaxis ◽  
Safety Outcome ◽  
Venous Thromboembolism Prophylaxis ◽  
Efficacy Outcome ◽  
Significant Difference ◽  
Dosing Intervals

Background: Appropriate chemical and/or mechanical venous thromboembolism prophylaxis is a high priority for clinicians. Unfortunately, there is little evidence-based guidance for clinical decision making for patients requiring both renal replacement therapy and VTE prophylaxis. The package insert for unfractionated heparin recommends 5000 units subcutaneously every 8 to 12 hours for VTE prophylaxis. Objective: The purpose of this study was to assess the two recommended dosing intervals and determine if there is a difference in terms of incidence of clotting or bleeding events. Methods: 159 patients were admitted to the UNC Health Care system between March 2014 and November 2019 and retrospectively screened for incidence of both the primary composite efficacy outcome (symptomatic or asymptomatic vascular event (VTE [DVT and PE]), ischemic event (stroke, TIA, or myocardial infarction), or death related to coagulopathy), the individual components of the composite outcome and the primary safety outcome. The results of the outcomes were then compared and analyzed using Fischer’s Exact test. Results: The two tailed p-values of the primary composite efficacy outcome (0.3517), the primary safety outcome (0.1571) and each of the composite outcomes (0.1556, 1.0000, 0.2297, respectively) showed no statistically significant difference. Conclusion: Results of this study show that there is no statistical difference between the dosing intervals of prophylactic UFH of every 8 to 12 hours, in terms of the incidence of VTE and major bleed events, for patients requiring CRRT. Suggesting that either interval is both efficacious and safe for the use of VTE prophylaxis.

Risk of venous thromboembolism and primary prophylaxis in cancer

2012 ◽  
Vol 32 (02) ◽  
pp. 132-137 ◽  
Author(s):  
C. Ay ◽  
I. Pabinger
Keyword(s):  
Risk Factors ◽  
Venous Thromboembolism ◽  
High Risk ◽  
Cancer Patients ◽  
Prediction Models ◽  
Critical Evaluation ◽  
Primary Prophylaxis ◽  
Vte Prophylaxis ◽  
Related Risk ◽  
Hospitalised Patients

SummaryVenous thromboembolism (VTE) is a common complication in patients with cancer that causes significant morbidity and mortality. Several patient-, tumour-and treatment-related risk factors for VTE in cancer patients have been identified. An effective and safe thromboprophylaxis in cancer patients at high risk of VTE is desirable. Recently, the identification of potential biomarkers and the development of risk scoring models for prediction of cancer-associated VTE have been published. Whether primary VTE prophylaxis based on risk assessment through these biomarkers and risk prediction models might be useful, is currently not yet known. However, thromboprophylaxis is clearly indicated in high-risk situations. While VTE prophylaxis is recommended in cancer patients undergoing surgery and in hospitalised patients with acute disease, studies in ambulatory cancer patients are still rare and evidence for primary VTE prophylaxis is currently limited. In this review, risk factors associated with VTE in cancer patients and current approaches of thromboprophylaxis in different settings, specifically in ambulatory cancer patients are subjected to a critical evaluation.

512 Single Center Experience with Venous Thromboembolism Prophylaxis for Obese Burn Patients

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S93-S93
Author(s):  
Brian McKinzie ◽  
Rabia Nizamani ◽  
Samuel W Jones ◽  
Felicia N Williams
Keyword(s):  
Body Weight ◽  
Venous Thromboembolism ◽  
High Risk ◽  
Peak Plasma ◽  
Total Body Surface Area ◽  
Retrospective Chart Review ◽  
Burn Patients ◽  
Thromboembolic Complications ◽  
Thromboembolism Prophylaxis ◽  
Vte Prophylaxis

Abstract Introduction Burn injured patients are at high risk of thromboembolic complications. Morbid obesity further increases risk for thromboembolic complications. Recent evidence supports the use of anti-Xa guided enoxaparin dosing for the prevention of venous thromboembolism (VTE) in high risk populations. Our objective was to evaluate the efficacy of enoxaparin 40mg twice daily in achieving prophylactic plasma anti-Xa levels in obese burn patients. Methods A retrospective chart review of an ABA-verified burn center from November 2018 until September 2019 identified patients who were either ≥100 kilograms (kg) or had a body mass index (BMI) ≥ 30 kg/m2 and were initiated on enoxaparin 40 mg twice daily for VTE prophylaxis. Patients were included if they were at least 18 years of age and received at least three sequential doses of enoxaparin with appropriately timed peak plasma anti-Xa levels to monitor efficacy. Patient demographics were analyzed, as well as body weight, BMI, and total body surface area (TBSA) burn. Statistical analysis was performed with student’s t-test for continuous data and Fischer’s exact test for categorical data. Results During the study period, 148 patients were screened with 44 patients included for analysis. Forty-one percent of the patients evaluated did not reach target peak plasma anti-Xa levels (0.2–0.5 IU/mL) on enoxaparin 40 mg twice daily. Patients who did not meet prophylactic target levels were more likely to be male (p&lt; 0.05) and have an increased body weight (129 +/- 24 kg versus 112 +/- 17 kg, p&lt; 0.05). Eleven out of 18 patients received dosage adjustments with subsequent anti-Xa levels available for follow-up assessment, of which an additional four patients required further dosage adjustment to meet goal peak plasma levels. Conclusions Current utilization of a fixed 40 mg twice daily regimen of enoxaparin for VTE prophylaxis is inadequate to meet target prophylactic peak plasma anti-Xa levels in the obese burn patient population. Dose adjusting enoxaparin to target peak plasma anti-Xa levels to reduce VTE rates in obese burn patients should be further evaluated. Applicability of Research to Practice This study demonstrates the need for more accurate dosing and evaluation of our dosing practices for VTE prevention. It also demonstrates the importance of having a Burn dedicated pharmacist in facilitating appropriate care.

Post-discharge compliance to venous thromboembolism prophylaxis in high-risk orthopaedic surgery

2012 ◽  
Vol 107 (02) ◽  
pp. 280-287 ◽  
Author(s):  
Juan Arcelus ◽  
Paulo Felicissimo ◽  
David Bergqvist ◽  
Keyword(s):  
Venous Thromboembolism ◽  
High Risk ◽  
Patient Education ◽  
Patient Compliance ◽  
Orthopaedic Surgery ◽  
Thromboembolism Prophylaxis ◽  
Post Discharge ◽  
Access To Treatment ◽  
Good Compliance ◽  
Vte Prophylaxis

SummaryVenous thromboembolism (VTE) risk persists for several weeks following high-risk orthopaedic surgery (HROS). The ETHOS registry evaluated post-operative VTE prophylaxis prescribed, and actual VTE prophylaxis received, compared with the 2004 American College of Chest Physicians (ACCP) guidelines in HROS patients. We performed a subanalysis of ETHOS to assess patient compliance with ACCP-adherent prophylaxis after discharge and the factors predicting poor compliance. Consecutive patients undergoing hip fracture surgery, total hip arthroplasty, or knee arthroplasty were enrolled at discharge from 161 centres in 17 European countries if they had received adequate in-hospital VTE prophylaxis. Data on prescribed and actual prophylaxis received were obtained from hospital charts and patient post-discharge diaries. Good compliance was defined as percentage treatment intake ≥80% with no more than two consecutive days without treatment. A total of 3,484 patients (79.4%) received ACCP-adherent anticoagulant prescription at discharge and 2,999 (86.0%) had an evaluable patient diary. In total, 87.7% of evaluable patients were compliant with prescribed treatment after discharge. The most common reason for non-compliance (33.4%) was “drug was not bought”. Injection of treatment was not a barrier to good compliance. Main factors affecting compliance related to purchase of and access to treatment, patient education, the person responsible for administering injections, country, and type of hospital ward at discharge. Within our study population, patient compliance with ACCP-adherent thromboprophylaxis prescribed at discharge was good. Improvements in patient education and prescribing practices at discharge may be important in further raising compliance levels in high-risk orthopaedic surgery patients.

Incidence and risk factors associated with venous thromboembolism following primary total hip arthroplasty in low-risk patients when using aspirin for prophylaxis

2021 ◽  
pp. 112070002199453
Author(s):  
Thomas A Howard ◽  
Caitlin S Judd ◽  
Gordon T Snowden ◽  
Robert J Lambert ◽  
Nick D Clement
Keyword(s):  
Venous Thromboembolism ◽  
Economic Status ◽  
Low Risk ◽  
Vte Prophylaxis ◽  
Factors Associated ◽  
Total Hip ◽  
Vein Thrombosis ◽  
Increased Risk ◽  
Significant Difference ◽  
Risk Patients

Aims: The primary aim was to assess the incidence of venous thromboembolism (VTE) following total hip replacements (THR) in a low-risk patient group when using 150 mg aspirin as the pharmacological component of VTE prophylaxis on discharge. The secondary aim was to identify factors associated with an increased risk of a VTE event in this low-risk group. Patients and methods: Retrospective review of a consecutive cohort of patients undergoing THR during a 63-month period. Patient demographics, socio-economic status, ASA grade, type of anaesthetic, length of surgery and BMI were recorded. A diagnosis of VTE was assigned to symptomatic patients with positive imaging for a deep vein thrombosis (DVT) and/or a pulmonary embolism (PE) within 8 weeks of surgery. Multivariate logistic regression modeling was used to identify factors associated with VTE after THR. Results: 3880 patients underwent THR during the study period, of which 2740 (71%) were low risk and prescribed aspirin for VTE prophylaxis. There were 34 VTE events, of which 15 were DVTs and 18 were PEs, with 1 patient diagnosed with both. The incidence of VTE was 1.2%, with no VTE-related deaths. Patients incurring a VTE postoperatively were more likely to be male (odds ratio [OR] 2.06, p = 0.022), of older age (OR 0.43, p = 0.047) and were more likely to be socially deprived (OR 0.32, p = 0.006). There was no significant difference with patients given low-molecular-weight heparin (LMWH) as an inpatient prior to discharge on aspirin ( p = 0.806), nor any difference with the type of anaesthetic used during surgery ( p = 0.719) Conclusions: Aspirin is a relatively safe and effective choice for VTE prophylaxis in low-risk patients undergoing THR. Male sex and age >70 years were twice as likely to sustain a VTE and patients from the most deprived socio-economic background are 3 times as likely.

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