The Impact Of a Standardized Protocol On Thromboprophylaxis, Venous Thromboembolism and Bleeding Rates In Hospitalized Patients With Hematological Malignancies

Abstract Background Venous thromboembolism (VTE) is a frequent complication in patients with underlying cancer. This risk is higher during hospitalization for acute medical conditions. Consequently, routine thromboprophylaxis is recommended in hospitalized cancer patients. A retrospective review of admissions to the Leukemia/Bone Marrow Transplant (LBMT) unit at our institution between January and June 2010 demonstrated that VTE prophylaxis was prescribed in only 6.6% of admissions. In March 2012, a mandatory VTE risk assessment and thromboprophylaxis protocol was introduced in the LBMT unit as part of a hospital-wide policy to improve thromboprophylaxis compliance for all hospitalized patients. Objectives The primary goal is to assess the impact of the VTE thromboprophylaxis protocol on the use of thromboprophylaxis in the LBMT unit. Secondary aims of this study are to evaluate the incidence of VTE (including catheter-related thrombosis [CRT]) and bleeding after the introduction of the protocol. Methods A retrospective chart review of all admissions to the Vancouver General Hospital LBMT unit between March 1, 2012 and February 28, 2013 was performed (intervention cohort [IC]). Only the first admission for each patient during the study period was included in the analysis. Data were extracted from electronic medical records using standardized forms. The primary outcome, rate of VTE prophylaxis, was compared to historical data from January 2010 to June 2010 (historical cohort [HC]). Results 361 patients were included in the IC and 166 patients were included in the HC. All baseline patient characteristics, thrombotic risk factors and bleeding risk factors were similar between the cohorts with the exception of the presence of thrombocytopenia (82.0% IC vs. 68.7% HC, p=0.001) (Table 1 ). At least one dose of thromboprophylaxis was prescribed in 14.0% of admissions in the IC vs. 6.6% of admissions in the HC. This increase was statistically significant (p=0.01). Despite the low prophylaxis prevalence, VTE was uncommon, occurring in only 1.9% patients in the IC (pulmonary embolism [PE] in 5 patients, CRT in 1 patient and left ventricular thrombus in 1 patient) vs. 2.4% patients in the HC (deep vein thrombosis +/- PE in 3 patients, CRT and PE in 1 patient) (p=0.7). In contrast, bleeding complications were frequent (even in the absence of anticoagulants), with 13.3% of patients in the IC and 19.3% of patients in the HC experiencing at least one bleeding episode (p=0.08). 22 patients (6.1%) in the IC and 8 patients (4.8%) in the HC died during the study period. While fatal bleeding events occurred in 2 patients in each cohort in the absence of anticoagulation, no deaths due to VTE were observed. Conclusions After introduction of a standardized protocol, VTE prophylaxis rate in hospitalized LBMT patients significantly increased by over 2-fold but remains low. No changes in bleeding and VTE rates were observed despite the increase in prophylaxis compliance. Although thrombocytopenia is likely the prime reason for withholding prophylaxis, further review is ongoing to elucidate the reasons why thromboprophylaxis was not prescribed in the majority of patients. Disclosures: No relevant conflicts of interest to declare.

Download Full-text

Maintained effectiveness of an electronic alert system to prevent venous thromboembolism among hospitalized patients

Thrombosis and Haemostasis ◽

10.1160/th08-05-0337 ◽

2008 ◽

Vol 100 (10) ◽

pp. 699-704 ◽

Cited By ~ 72

Author(s):

Ramón Lecumberri ◽

Margarita Marqués ◽

María Díaz-Navarlaz ◽

Elena Panizo ◽

Jon Toledo ◽

...

Keyword(s):

Venous Thromboembolism ◽

Hospitalized Patients ◽

Medical Patients ◽

Alert System ◽

Thrombotic Risk ◽

Vte Prophylaxis ◽

Sustained Reduction ◽

Alert Program ◽

The Impact ◽

First Time

SummaryDespite current guidelines, venous thromboembolism (VTE) prophylaxis is underused. Computerized programs to encourage physicians to apply thromboprophylaxis have been shown to be effective in selected populations. Our aim was to analyze the impact of the implementation of a computer- alert system for VTE risk in all hospitalized patients of a teaching hospital. A computer program linked to the clinical record database was developed to assess all hospitalized patients’VTE risk daily. The physician responsible for patients at high risk was alerted, but remained free to order or withhold prophylaxis. Over 19,000 hospitalized, medical and surgical, adult patients between January to June 2005 (pre-intervention phase), January to June 2006 and January to June 2007 (postintervention phase), were included. During the first semesters of 2006 and 2007, an electronic alert was sent to 32.8% and 32.2% of all hospitalized patients, respectively. Appropriate prophylaxis among alerted patients was ordered in 89.7% (2006) and 88.5% (2007) of surgical patients, and in 49.2% (2006) and 64.4% (2007) of medical patients. A sustained reduction of VTE during hospitalization was achieved, Odds ratio (OR): 0.53, 95% confidence interval (CI) (0.25–1.10) and OR: 0.51, 95%CI (0.24–1.05) during the first semesters of 2006 and 2007 respectively, the impact being significant (p<0.05) among medical patients in 2007, OR: 0.36, 95%CI (0.12–0.98). The implementation of a computer- alert program helps physicians to assess each patient’s thrombotic risk, leading to a better use of thromboprophylaxis, and a reduction in the incidence of VTE among hospitalized patients. For the first time, an intervention aimed to improveVTE prophylaxis shows maintained effectiveness over time.

Download Full-text

Impact of Postoperative Venous Thromboembolism on Postoperative Morbidity, Mortality, and Resource Utilization after Hepatectomy

The American Surgeon ◽

10.1177/000313481508101220 ◽

2015 ◽

Vol 81 (12) ◽

pp. 1216-1223 ◽

Cited By ~ 2

Author(s):

Timothy E. Newhook ◽

Damien J. Lapar ◽

Dustin M. Walters ◽

Shruti Gupta ◽

Joshua S. Jolissaint ◽

...

Keyword(s):

Risk Factors ◽

Venous Thromboembolism ◽

Fold Increase ◽

The United States ◽

Albumin Level ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Resource Usage ◽

Vte Prophylaxis ◽

The Impact

The impact of venous thromboembolism (VTE) after hepatectomy on patient morbidity, mortality, and resource usage remains poorly defined. Better understanding of thromboembolic complications is needed to improve perioperative management and overall outcomes. About 3973 patients underwent hepatectomy within NSQIP between 2005 and 2008. Patient characteristics, operative features, and postoperative correlates of VTE were compared with identify risk factors for VTE and to assess its overall impact on postoperative outcomes. Overall incidence of postoperative VTE was 2.4 per cent. Risk factors for postoperative VTE included older age, male gender, compromised functional status, degree of intraoperative blood transfusion, preoperative albumin level (all P < 0.05), and extent of hepatectomy ( P = 0.004). Importantly, major postoperative complications, including acute renal failure, pneumonia, sepsis, septic shock, reintubation, prolonged ventilation, cardiac arrest, and reoperation were all associated with higher rates of VTE (all P < 0.05). Operative mortality was increased among patients with VTE (6.5% vs 2.4%, P = 0.03), and patients with VTE had a 2-fold increase in hospital length of stay (12.0 vs 6.0 days, P < 0.001). Postoperative VTE remains a significant source of morbidity, mortality, and increased resource usage after hepatectomy in the United States. Routine aggressive VTE prophylaxis measures are imperative to avoid development of VTE among patients requiring hepatectomy.

Download Full-text

Is prolonged immobilization a risk factor for symptomatic venous thromboembolism in elderly bedridden patients?

Thrombosis and Haemostasis ◽

10.1160/th03-07-0481 ◽

2004 ◽

Vol 91 (03) ◽

pp. 538-543 ◽

Cited By ~ 37

Author(s):

Ora Paltiel ◽

Michael Bursztyn ◽

Moshe Gatt

Keyword(s):

Risk Factors ◽

Venous Thromboembolism ◽

Early Period ◽

Thromboembolic Events ◽

Historical Cohort ◽

Increased Risk ◽

Venous Thromboembolic Events ◽

Venous Thromboembolic ◽

Prolonged Immobilization ◽

The Impact

SummaryProlonged immobilization and advanced age are considered to be important risk factors for venous thromboembolism (VTE). Nevertheless, the need for VTE prophylaxis in long-term bedridden patients is not known. To assess whether very prolonged immobilization (i.e. over three months) carries an increased risk for clinically apparent VTE, we performed a historical-cohort study of nursing home residents during a ten-year period. Data concerning patient’s mobility and incidence of overt deep vein thrombosis or pulmonary embolism were registered. The mean resident age was 85 ± 8.4 years. Eighteen mobile and eight immobile patients were diagnosed with clinically significant thromboembolic events, during 1137 and 573 patient-years of follow up, respectively. The incidence of venous thromboembolic events was similar in both chronically immobilized and mobile patient groups, 13.9 and 15.8 per thousand patient years, respectively (p = 0.77). The rate ratio for having a VTE event in the immobilized patient group as compared with the mobile group was 0.88 (95% Confidence Interval (CI) 0.33 to 2.13). When taking into account baseline characteristics, risk factors and death rates by various causes, no differences were found between the two groups. In conclusion, chronically immobile bedridden patients are no more prone to clinically overt venous thromboembolic events than institutionalized mobile patients. Until further studies are performed concerning the impact of very prolonged immobilization on the risk of VTE, there is no evidence to support primary prevention after the first three months of immobilization. Evidence for efficacy or cost effectiveness beyond this early period is not available.

Download Full-text

Risk assessment and prevention of venous thromboembolism among hospitalized patients: Results of the regional multicenter study

Atherothrombosis Journal ◽

10.21518/2307-1109-2021-11-1-26-40 ◽

2021 ◽

pp. 26-40

Author(s):

A. B. Sugraliyev ◽

Sh. S. Aktayeva ◽

Sh. B. Zhangelova ◽

S. A. Shiller ◽

Zh. M. Kussymzhanova ◽

...

Keyword(s):

Risk Factors ◽

Venous Thromboembolism ◽

Multicenter Study ◽

Bed Rest ◽

Primary Objective ◽

Hospitalized Patients ◽

Public Health Issue ◽

Medical Patients ◽

Pharmacological Prophylaxis ◽

Vte Prophylaxis

Introduction. Venous thromboembolism (VTE) is a major public health issue that is frequently underestimated. The primary objective of this multicenter study was to identify patients at risk for VTE, and to define the rate of patients receiving appropriate prophylaxis in the regions of Kazakhstan.Materials and methods. Standardized case report forms were filled by trained medical doctors on one predefined day in selected hospitals. Data were analyzed by independent biostatistician. Risk of VTE was categorized according to Caprini score which was recommended by 2004 American College of Chest Physicians (ACCP) guidelines.Results. 432 patients from 4 regions of Kazakhstan; 169 (39.10%) medical patients and 263 (60.9%) surgical patients were eligible for the study. Patients were at low (10%), moderate (19.2%), high (33.6%) and very high risk (37.3%) for VTE. The main risk factors (RF) of VTE among hospitalized patients were heart failure (HF), obesity, prolonged bed rest, and the presence of acute non-infective inflammation. From total number of hospitalized patients with RF with indications to VTE prophylaxis, 58.1% of patients received pharmacological prophylaxis and only 24.6% of them received VTE prophylaxis according ACCP. On the other hand, 23.5% patients with the risk of VTE but who were not eligible for it received pharmacological prophylaxis.Conclusion. These results indicate the existence of inconsistency between eligibility for VTE prophylaxis on one hand and its application in practice (p < 0.001). Risk factors for VTE and eligibility for VTE prophylaxis are common, but VTE prophylaxis and guidelines application are low.

Download Full-text

Perioperative Antithrombotic Therapy Management and Venous Thromboembolism Prophylaxis

10.2310/vasc.2202 ◽

2020 ◽

Author(s):

Herbert Chen ◽

Irene Lou

Keyword(s):

Risk Factors ◽

Venous Thromboembolism ◽

Antiplatelet Therapy ◽

Antithrombotic Therapy ◽

Bleeding Complications ◽

Thromboembolism Prophylaxis ◽

Therapy Management ◽

Vte Prophylaxis ◽

Increased Risk ◽

Perioperative Anticoagulation

The management of perioperative anticoagulation, antiplatelet therapy, and perioperative venous thromboembolism (VTE) prophylaxis is essentially a balancing act between patient risk factors for thrombosis and surgical risk factors for bleeding. The purpose of this review is to assist surgeons with the identification of patients at increased risk for thromboembolism when antithrombotic therapy is interrupted, patients for whom bridging anticoagulation should be considered, patients who require perioperative VTE prophylaxis, and patients at increased risk for bleeding complications and to briefly review the literature and major guidelines regarding perioperative antithrombotic therapy management and perioperative VTE prophylaxis. Figures show approaches to the management of perioperative anticoagulation, antiplatelet therapy, and VTE prophylaxis. This review contains 2 figures, 7 tables, and 61 references. Keywords: Venous thromboembolism, pulmonary embolism, anticoagulation, surgery, perioperative period, prophylaxis

Download Full-text

Impact of a Venous Thromboembolism Prophylaxis “Smart Orderset”: Improved Compliance, Fewer Events

Blood ◽

10.1182/blood.v118.21.172.172 ◽

2011 ◽

Vol 118 (21) ◽

pp. 172-172

Author(s):

Amer M. Zeidan ◽

Michael B. Streiff ◽

Syed-Rafay Ahmed ◽

Peggy S Kraus ◽

Deborah Hobson ◽

...

Keyword(s):

Risk Factors ◽

Decision Support ◽

Venous Thromboembolism ◽

Major Bleeding ◽

Vte Prophylaxis ◽

Patient Demographics ◽

Medicine Service ◽

Before And After ◽

Pharmacologic Prophylaxis ◽

The Impact

Abstract Abstract 172FN2 Introduction: Venous Thromboembolism affects 900,000 Americans annually. Prophylaxis reduces the risk of VTE by 60% but many patients do not receive risk-appropriate VTE prophylaxis. We developed mandatory computer decision support “smart ordersets” (i.e. electronic menus with DVT prophylaxis recommendations) to improve our institution's VTE prophylaxis performance. The ordersets require providers to respond to 2 questions that assess VTE risk factors and contraindications to pharmacologic prophylaxis. Using these answers along with known patient demographics, the orderset gives providers an evidence-based risk-appropriate VTE prophylaxis recommendation. Methods: To study the impact of Medicine service-specific orderset on compliance with the 2008 American College of Chest Physicians (ACCP) VTE prophylaxis guideline and clinical outcomes, we conducted a retrospective cohort chart review of consecutive patients admitted to the Medicine service during one month immediately prior to (November 2007) and a single month subsequent to (April 2010) orderset launch. Data collection included patient demographics, VTE risk factors, and use and type of VTE prophylaxis. Patient characteristics before and after implementation of the protocol were compared. The primary outcome measures were compliance with thromboprophylaxis guidelines in patients at risk for VTE and the 90-day VTE rate. Secondary outcomes were bleeding events and 30-day mortality. Outcomes were compared by Student's t-test and Fisher's exact test. Results: The before and after cohorts contained 1,025 and 1,057 patients, respectively. Demographic characteristics and contraindications to pharmacologic prophylaxis were similar between groups. (Table 1) Some VTE risk factors were more prevalent in the before group. (Table 1) ACCP compliant prophylaxis increased significantly from 68.3% to 85.9% (p <.0001). Provider choices for prophylaxis changed with an increase in mechanical prophylaxis and twice daily heparin in the post-orderset implementation cohort. (Table 2) Radiographically-documented symptomatic VTE by day 90 post-hospital discharge declined from 2.8% to 0.7% after orderset implementation (p=0.001). There was also a trend toward fewer in-hospital VTE (0.8% versus 0.2%, p=0.06). (Figure 1) Major bleeding remained unchanged (0.3% to 0.1%, p=0.47). Conclusion: A VTE prophylaxis computerized decision support “smart orderset” improves ACCP-compliant VTE prophylaxis and results in lower risk of symptomatic VTE without an increase in major bleeding. Disclosures: Streiff: BristolMyers Squibb: Research Funding; sanofi-aventis: Consultancy; Daiichi-Sankyo: Consultancy; Eisai: Member of study outcome adjudication committee; sanofi-aventis: Honoraria.

Download Full-text

Perioperative Antithrombotic Therapy Management and Venous Thromboembolism Prophylaxis

10.2310/surg.2202 ◽

2020 ◽

Author(s):

Herbert Chen ◽

Irene Lou

Keyword(s):

Risk Factors ◽

Venous Thromboembolism ◽

Antiplatelet Therapy ◽

Antithrombotic Therapy ◽

Bleeding Complications ◽

Thromboembolism Prophylaxis ◽

Therapy Management ◽

Vte Prophylaxis ◽

Increased Risk ◽

Perioperative Anticoagulation

Download Full-text

Contemporary approach to primary prophylaxis of venous thromboembolism regarding the impact of risk factors on anticoagulation therapy duration

Srpski arhiv za celokupno lekarstvo ◽

10.2298/sarh1404249a ◽

2014 ◽

Vol 142 (3-4) ◽

pp. 249-256

Author(s):

Nebojsa Antonijevic ◽

Ljubica Jovanovic ◽

Valentina Djordjevic ◽

Ivana Zivkovic ◽

Miodrag Vukcevic ◽

...

Keyword(s):

Risk Factors ◽

Heart Failure ◽

Venous Thromboembolism ◽

Anticoagulation Therapy ◽

Chronic Obstructive ◽

Medical Illness ◽

Medical Patients ◽

Class Iii ◽

Vte Prophylaxis ◽

The Impact

Adequate thromboprophylaxis primarily requires timely detection of reversible and irreversible risk factors of venous thromboembolism (VTE) and their categorization. It is important to note that the highest percentage of VTE episodes occur in non-surgical (medical) patients and that VTE develops in a large number of surgical patients upon hospital discharge; this emphasizes the need for adequate VTE prevention in inflammatory diseases, acute medical illness and other medical diseases as well as for prolonging and optimizing the anticoagulant regimen after surgical intervention in the primary VTE prophylaxis. As almost completely unrecognized and neglected major risk factors of VTE in clinical practice, we particularly point out the chronic obstructive pulmonary disease (COPD) and heart failure, especially in NYHA functional class III and IV patients with significantly reduced left heart ventricle. It is necessary to raise clinicians? awareness of a potential danger from wrongly and one-sidedly interpreted dyspnea and coughing signs in patients with COPD as typical symptoms of basic respiratory disease as well as from ascribing the signs of disease aggravation in heart failure patients exclusively to cardial status worsening, neglecting the possibility of having unrecognized and untreated pulmonary embolism at issue. Contemporary way of life enhances the development of new VTE risk factors such as traveler?s thrombosis, in particular during long-haul flights as well as in individuals sitting at a computer for prolonged periods (e-thrombosis). Determining and recognizing VTE risk factors, especially those formerly neglected nonsurgical ones and simultaneous presence of multiple risk factors within a given period is required for defining an adequate anticoagulant regimen in primary VTE prophylaxis for surgical and non-surgical (medical) patients.

Download Full-text

Scoring Systems for Estimating Risk of Venous Thromboembolism in Hospitalized Medical Patients

Seminars in Thrombosis and Hemostasis ◽

10.1055/s-0036-1597901 ◽

2017 ◽

Vol 43 (05) ◽

pp. 460-468 ◽

Cited By ~ 10

Author(s):

Paolo Prandoni ◽

Sofia Barbar

Keyword(s):

Risk Factors ◽

Venous Thromboembolism ◽

Scoring Systems ◽

Cost Effective ◽

Assessment Model ◽

Medical Patients ◽

Thrombotic Risk ◽

Vte Prophylaxis ◽

Vein Thrombosis ◽

Medical Inpatients

AbstractDeep vein thrombosis and pulmonary embolism are associated with considerable morbidity and mortality in hospitalized patients, accounting for up to 10% of hospitalization-related deaths in both surgical and medical patients. Pharmacologic thromboprophylaxis has been demonstrated to be effective, safe, and cost-effective in preventing hospital-acquired venous thromboembolism (VTE) among medical inpatients, and clinician awareness of thrombotic risk promotes prescription of thromboprophylaxis. Guidelines recommend stratification of thrombotic risk for all patients and, unless contraindicated, administration of VTE prophylaxis. Based on several recognized predisposing and exposing risk factors for VTE, several scoring systems have been published in the past 15 years. Borrowing models developed in the surgical setting, recognized risk factors for VTE complications in medical inpatients have been combined in different weighted scores and derived and validated in heterogeneous medical populations. Although the perfect score, balancing thrombotic and hemorrhagic risk, has probably not yet been built, the adoption of an easy-to-use risk assessment model has the potential to support physicians in properly stratifying VTE risk in medical inpatients, tailoring thromboprophylaxis prescription.

Download Full-text