Know Options for Preventing VTE
Know what the literature says about options for preventing VTE
Theme #2: Instances of clear superiority (or inferiority) do exist among the main prophylaxis options, but for just a few patient groups.
One of your team’s fundamental duties is to come up with a way to recommend (as well as judge) the appropriateness of one prophylaxis option over another. For this reason, the second thing to know about the VTE literature is where clear evidence exists to recommend a particular method of prophylaxis over others.
Your team should make sure to know that:
- in most patient groups, especially those at intermediate risk, LMWH has no demonstrated superiority over TID SQ Heparin
- certain higher risk patient groups (e.g. hip fracture, total knee replacement, etc) should receive LMWH rather than SQ UFH.
- in certain patient groups the adequacy of BID SQ Heparin has not been proven
- in higher risk patient groups the addition of mechanical prophylaxis to a pharmacologic regimen may provide an additive benefit
- certain patient groups should not receive certain pharmacologic agents or doses
- certain patient groups should receive pharmacologic doses in close coordination with other events (e.g. surgery, neuroaxial blockade, etc.) or with special knowledge by involved physicians (e.g. spine surgeons)
Ok, so the most appropriate choice of VTE prophylaxis depends on the patient and the circumstances of the hospital stay. What does the literature say about how to get the risk assessment done and appropriate prophylaxis ordered reliably? Depending on your viewpoint, the answer is either frustrating or an open invitation to be creative: when it comes to proven approaches to improve VTE prophylaxis, the quality improvement literature is not particularly helpful.
Theme #3: Few quality improvement strategies have been shown to get the right prophylaxis to the right patient at sustainable and acceptable rates that can be replicated readily by other institutions.
Notable success stories exist, but with potentially limited generalizability. One example includes a study of electronic alerts from the March 2005 issue of the New England Journal of Medicine which profiles an intervention in an academic setting with CPOE, electronic decision support, and a high baseline rate of prophylaxis. Another example is a study from the Nov-Dec 2006 issue of the Journal of Hospital Medicine that describes a robust, monthly audit-and-feedback of physician performance superimposed on robust, monthly educational offerings for patients cared for by the medicine housestaff. Non-teaching hospitals or those without CPOE would be unable to replicate these strategies. The literature does not yet offer a predictably reliable, widely applicable approach. However, based on our early collaborative experience across multiple sites we offer here what we believe is a generalizable, predictive framework.
We recommend that you begin your review of the evidence base for VTE prophylaxis by studying the Society of Hospital Medicine’s slide set presentation Prevention of Venous Thromboembolism. You may download and adapt it as your team sees fit. To find the presentation, click the hyperlink above or navigate to the Teaching and Learning Slide Sets page under the Education Resources tab of this Resource Room. The Literature Review section of the VTE QI Resource Room also The 7th ACCP Conference article heads up a suggested reading list for the VTE literature below.
After becoming very familiar with the evidence base and best practice, you will be ready for the first significant step in your quality improvement effort. Not only will this step permit you to translate evidence into practice, but it will also put in your hands the foundation of everything else you will do to systematically prevent hospital-acquired VTE, from interventions to performance tracking.
Suggested reading
Published Papers Looking at VTE Risk Factors or VTE Risk Assessment
Samama MM, Dahl OE, Mismetti P, Quinlan DJ, Rosencher N, Cornelis M, de Vries H, van Beusekom I, Kahan JP. (2006) An electronic tool for venous thromboembolism prevention in medical and surgical patients. Haematologica. 2006 Jan;91(1):64-70.
Labarère, José, Bosson, Jean-Luc, Bergmann, Jean-François & Thilly, Nathalie (2004)
Agreement of Four Competing Guidelines on Prevention of Venous Thromboembolism and Comparison with Observed Physician Practices.
Journal of General Internal Medicine 19 (8), 849-855.
Labarere, J., Bosson, J.-L., Brion, J.-P., Fabre, M., Imbert, B., Carpentier, P. & Pernod, G. (2004)
Validation of a clinical guideline on prevention of venous thromboembolism in medical inpatients: a before-and-after study with systematic ultrasound examination.
Journal of Internal Medicine 256 (4), 338-348.
Caprini, J., Arcelus, J., & Reyna, J. (2001)
Effective Risk Stratification of Surgical and Nonsurgical Patients for Venous Thromboembolic Disease.
Seminars in Hematology 38 (2) Suppl 5, 12-19.
Motykie, G., Zebala, L., Caprini, J., Lee, C., Arcelus, J., Reyna, J., Cohen, E., Courtney, T., & Sullivan, L. (2000)
A Guide to Venous Thromboembolism Risk Factor Assessment.
Journal of Thrombosis and Thrombolysis 9, 253-262.
Anderson, F., Spencer, F. (2003)
Risk Factors for Venous Thromboembolism.
Circulation 107, I-9-I-16.
Gensini, G., Prisco, D., Falcini, M., Comeglio, M., & Colella, A. (1997)
Identification of Candidates for Prevention of Venous Thromboembolism.
Seminars in Thromboembolism and Hemostasis 23 (1), 55-67.
Haas, S. (2002)
Venous Thromboembolic Risk and Its Prevention in Hospitalized Medical Patients.
Seminars in Thromboembolism and Hemostasis 28 (6), 577-583.
National Experts’ Consensus Panels for Clinical Excellence in Thrombosis Management, Goldhaber, S (Chair). (2003)
Prophylaxis of Venous Thromboembolism in The Hospitalized Medical Patient.
Hospital Medicine Reports 1-20.
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