Know Options for Preventing VTE

Know what the literature says about options for preventing VTE

Reality #2: Instances of clear superiority (or inferiority) do exist among prophylaxis options, but for just a few patient groups.

• in medical patients, fondaparinux and low-molecular-weight heparins (LMWH) enoxaparin and dalteparin have efficacy comparable to TID SQ Heparin, but offer lower complication rates and other advantages potentially important to patients and nursing ^18-21
• in certain higher risk patient groups (e.g. hip and knee replacement, trauma, and spinal cord injury) LMWH has demonstrated superiority over SQ Heparin ^{10, 22-25}
• in certain patient groups, extending prophylaxis with LMWH to approximately 5 weeks is more effective than 1 week (e.g. hip replacement, surgery for cancer, and possibly medical patients with reduced mobility) ^{10, 26}
• in certain patient groups, the adequacy of BID SQ Heparin has not been proven
• in very high risk patient groups, the addition of mechanical prophylaxis to a pharmacologic regimen may offer added benefit
• certain patient groups should not receive certain pharmacologic agents or doses, or should receive smaller doses of LMWH (e.g. creatinine clearance < 30 cc/minute)
• certain patient groups should receive pharmacologic doses in close coordination with other events (e.g. surgery, neuroaxial blockade) or with special knowledge by involved physicians (e.g. spine surgeons)

Reality #3: In the quality improvement literature no strategy has yet been described for getting the right prophylaxis to the right patient at sustainable and acceptable rates in a way that can be readily replicated by other institutions.

The typical successful strategy described in the literature profiles excellent use of special local resources, but with limited transferability. Electronic alerts have raised the prevalence of VTE prophylaxis, but in an academic setting with computerized physician order entry (CPOE), electronic decision support, and a high baseline prevalence of VTE prophylaxis.27 In another academic setting, a monthly division director-led audit-and-feedback of physician performance was combined successfully with monthly educational offerings for patients cared for by the medicine house staff. 28 Replicating such strategies in non-teaching or non-CPOE settings would not be possible. More generally, because QI study designs tend not to confirm sustainability or reproducibility, the ability to articulate or judge discrete underlying mechanisms is limited.

The key point at this stage, however, is that familiarity with the evidence base positions the team to draft a “VTE protocol,” the document that becomes the foundation for the rest of the effort to prevent HA-VTE, from interventions through 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.