Transcript Cost-Consciousness Assignment

Cost-Consciousness
Assignment
Ollie Ross
DSR 2
Adherence to ACP DVT
prophylaxis guidelines
• Objective: Evaluate adherence to ACP
DVT prophylaxis guidelines in a LBVA
ward team and determine if excessive
prophylaxis is being utilized
ACP Guidelines
• Venous Thromboembolism Prophylaxis
in Hospitalized Patients: A Clinical
Practice Guideline From the American
College of Physicians. Qaseem, A.,
Chou, R., et al. Annals of Internal
Medicine. 2011;155:625-632
ACP Recommendation 1
• ACP recommends assessment of the
risk for thromboembolism and bleeding
in medical (including stroke) patients
prior to initiation of prophylaxis of
venous thromboembolism (Grade:
strong recommendation, moderatequality evidence).
ACP Recommendation 1
• “Many risk assessment tools are
available for estimating
thromboembolism risk, but the current
evidence is insufficient to recommend a
validated tool”
• Note: ACCP recommends patients at
low risk for DVT/PE require NO
prophylaxis
Padua Risk Assessment
Model
• 3 points: Cancer, past VTE, immobility,
thrombophilic condition
• 2 points: Trauma or surgery in past month
• 1 point: Age 70 or older, CHF, AMI, Ischemic
CVA, BMI 30 or greater, hormone use, acute
infectious or rheumatologic disorder
• Score <4 considered Low Risk
ACP Recommendation 2
• ACP recommends pharmacologic
prophylaxis with heparin or a related
drug for venous thromboembolism in
medical (including stroke) patients
unless the assessed risk for bleeding
outweighs the likely benefits (Grade:
strong recommendation, moderatequality evidence).
ACP Recommendation 3
• ACP recommends against the use of
mechanical prophylaxis with graduated
compression stockings for prevention of
venous thromboembolism (Grade:
strong recommendation, moderatequality evidence).
ACP Recommendation 3
• “In patients at high risk for bleeding events or
in whom heparin is contraindicated for other
reasons, intermittent pneumatic compression
may be a reasonable option, because
evidence suggests that it is beneficial in
surgical patients”
• “However, intermittent pneumatic
compression has not been sufficiently
evaluated as a stand-alone intervention in
medical patients to reliably estimate benefits
and harms”
Methods
• One LBVA ward team with over 10
patients was chosen at random
• EMR was reviewed to determine what
DVT prophylaxis were ordered
• Patients were seen to determine if
SCDs were in place
Results
• 11 patients; all Padua score 4 or greater
• 6/11 had only heparin SQ ordered
• 2/11 had only SCDs ordered (active bleeding/ surgery
planned), but SCDs were not in place (bilateral
urostomy bags/ patient refusal)
• 1/11 had heparin SQ and SCDs ordered but SCDs
were not in place
• 1/11 had coumadin (A-fib) and SCDs ordered and
SCDs were in place
• 1/11 had INR >3 (cirrhosis) so no DVT ppx was
ordered
Results
• 2/11 had both anticoagulation and
SCDs ordered, but only 1/11 was
actually receiving both
Take Home Point
• ACP DVT prophylaxis guidelines do not
recommend simultaneous use of both
anticoagulation and mechanical
compression devices
• Simultaneous use of both
anticoagulation and SCDs may be
superfluous