Transcript VTE Prevention - Quality Improvement Strategies Reducing

VTE Prevention
Quality Improvement Strategies
VTE: venous thromboembolism-DVT/PE
Jordan Messler, MD, SFHM
Morton Plant Hospitalists
Medical Director
Pulmonary Embolism (PE)
Goldhaber SZ. N Engl J Med. 1998;339(2):93-104.
Objectives
• Understand the epidemiology of VTE and the
impact of VTE prevention
• Identify quality improvement strategies to
improve VTE prevention at the local level
• Understand some of the latest updates in
VTE prevention guidelines
• VTE prevention basics
• Quality Improvement strategies
• ACCP 2012 guidelines
• Other VTE prophylaxis pearls
VTE: A Major Source of
Mortality and Morbidity
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350,000 to 650,000 with VTE per year
100,000 to > 200,000 deaths per year
Most are hospital related
VTE is primary cause of fatality in half– More than HIV, MVAs, Breast CA combined
– Equals 1 jumbo jet crash / day
• 10% of hospital deaths
– May be the #1 preventable cause
• Huge costs and morbidity (recurrence, postthrombotic syndrome, chronic PAH)
Surgeon General’s Call to Action to Prevent DVT and PE 2008 DHHS
A 500 bed hospital can expect 250
hospital acquired DVT/PE per year.
Half of these are preventable
Going from 50 to 90% VTE prophylaxis
over the course of a year will avoid
68 DVTs, 29 PEs, & 5 Deaths
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VTE Consequences
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Leg swelling, discomfort (DVT)
Dyspnea, chest pain, hemoptysis, hypoxemia (PE)
Extended hospital LOS
Fatal PE (RV failure)
≥3 months of anticoagulant treatment
Post thrombotic syndrome
Chronic thromboembolic pulmonary HTN (~4%)
Pengo et al. N Engl J Med. 2004;350:2257-2264.
Risk Factors for VTE
Stasis
Hypercoagulability
Age > 40
Anesthesia
Immobility
Heart Failure
Stroke
Paralysis
Spinal cord injury
Polycythemia
Severe COPD
Obesity
Varicose Veins
Cancer
Inflammatory Bowel
Medications
Nephrotic Syndrome
Sepsis
Smoking
Pregnancy
Thrombophilia
Endothelial
Damage
Surgery
Prior VTE
Central lines
Trauma
Most hospitalized patients have at
least one risk factor for VTE
Anderson FA Jr. & Wheeler HB. Clin Chest Med 1995;16:235.
Bick RL & Kaplan H. Med Clin North Am 1998;82:409.
Cases per 10,000 person-years
The VTE Population: Who gets clots?
1000
100
Recently hospitalized
10
1
Hospitalized patients
Community residents
Heit JA et al. Mayo Clin Proc. 2001; 76:1102-10.
Many Surgical Patients At-Risk
• 2003 Nationwide Inpatient Sample
• Adult surgical patients, LOS ≥2 days
• 7.8 million surgical discharges
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44% low risk
15% moderate risk
24% high risk
17% very high risk
• 4.4 million at risk for VTE
Anderson et al. Am J Hematol. 2007;82:777-782.
Effective, Safe, and Cost-Effective
• Pharmacologic prophylaxis substantially reduces
the risk for VTE
• Bleeding complications are rare
• HIT: a serious but relatively rare complication of
heparin therapy
– 2.37% with prolonged UFH in ill perioperative
patients
– 0.06% with LMWH
– Monitoring for HIT is warranted
•
Cost-effectiveness of VTE prophylaxis well
documented
HIT = heparin-induced thrombocytopenia
LMWH = low molecular weight heparin
UFH = unfractionated heparin
Geerts WH et al. Chest. 2008; 133(6 suppl):381S-453S.
Shojania KG et al. Making health care safer.
Martel N et al. Blood. 2005; 106:2710-5.
VTE Prophylaxis: Medical Patients
Anticoagulants vs. Placebo Trials
Patients with VTE (%)
16
14.9
Placebo
LMWH
12
RRR=63%
p=0.0002
8
5.5
4
0
RRR=49.5%
p=0.0029
10.5
RRR=44%
p=0.0015
5.6
5
2.8
MEDENOX
PREVENT
ARTEMIS
Enoxaparin
Dalteparin
Fondaparinux
n=1102
n=3706
n=849
Samama MM et al. N Engl J Med. 1999; 341:793-800.
Leizorovicz A et al. Circulation. 2004; 110:874-9.
Cohen AT et al. BMJ. 2006; 332:325-9.
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VTE Prophylaxis Meta-Analysis
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9 studies
19,958 medical patients
Anticoagulant prophylaxis vs no treatment
Results
– 57% reduction in RR for symptomatic PE
– 62% reduction in RR for fatal PE
– 53% reduction in DVT
– No significant increase in major bleeding
Dentali F, et al. Ann Intern Med. 2007;146:278-288.
Registries Highlight the Underuse of VTE
Prophylaxis in Hospitalized Patients
15,000 patients
1,800 patients
68,000 patients
IMPROVE1
CURVE2
ENDORSE3
90% at risk
60% any VTE
prophylaxis
23% any VTE
prophylaxis (16%
appropriate)
40% appropriate VTE
prophylaxis
Only a minority of hospitalized medical patients receive
appropriate VTE prophylaxis
1.Tapson VF et al. Chest. 2007; 132:936-45.
2. Kahn SR et al. Thromb Res. 2007; 119:145-55.
3. Cohen AT et al. Lancet. 2008; 371:387-94.
Adherence to Guidelines
• Premier Database: 429 Hospitals, 2005 and 2006
• Appropriate prophylaxis: type, dose, daily, duration
according to 7th ACCP-2004
Prophylaxis
Any(>1 dose)
Medical
N=201,224
66%
Surgical
N=188,800
78%
Appropriate
13%
16%
Amin-JHM 2009;4:E15
CT Pulmonary Angiography
Goldhaber SZ. N Engl J Med. 1998;339(2):93-104.
Kearon SF. CMAJ. 2003;168:183-194.
Why don’t we do better?
• Competing Priorities
• National Policies / Incentives / Initiatives / Accreditation not
all in place
• Lack of awareness of guidelines, battling guidelines
• Underestimation of clot risk, overestimation of bleeding risk
• Validated and practical risk assessment models needed
• Measurement Issues
• Translating complicated guidelines into everyday practice is
difficult
• Medical training failures (QI and systems re-design)
• Failure to use a good QI framework
My First Algorithm for Process Improvement
VTE Prevention Guides
www.ahrq.gov/qual/vtguide
Maynard G, Stein J. Agency for Healthcare Research and Quality.
August 2008. http://www.ahrq.gov/qual/vtguide/
Quality Improvement is…
• Focus on processes of care
• Reduced variation by shifting entire practice
• A change in the design of care
Quality Improvement is NOT…
• Forcing people to work harder / faster / safer
• Traditional quality assurance or peer review
• Creating order sets or protocols without monitoring use
or effect
VTE Prophylaxis
A Multidisciplinary Approach
• TEAM
• AIM STATEMENT: Goals
• Measurement
• Analyze Process
• STANDARDIZE based on best evidence
• Identification and Mitigation
Maynard G, Stein J. Agency for Healthcare Research and Quality. August 2008.
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Hierarchy of Reliability
Most hospitals at Level 1 or 2
Predicted Prophylaxis
RATE
LEVEL
1
2
No Protocol- “state of nature”
40%
Decision Support Exists
50%
Doesn’t link to order writing OR
Prompts within orders but no decision support
3
4
5
Protocol Well Integrated
65-85%
Protocol Enhanced
90%
Oversights identified and addressed in real
time
95+%
Maynard G, Stein J. Agency for Healthcare Research and Quality. August 2008.
The Multidisciplinary Team:
The Engine of Quality Improvement
• Backbone of quality improvement (QI) efforts
• Impact the interventions developed AND their
implementation
• Synergistic
• Productive capacity = more than the sum of all
individual team members taken together
Metrics are Essential for
VTE Prevention Efforts
• Key component of institutional support
• Use consistent metrics over time
• Report results regularly to med staff/ admin
Different Types of Metrics in
VTE Prevention Efforts
Structure
Dedicated quality improvement team?
Standardized order sets, protocols?
Electronic Health Record? CPOE?
Process
% with VTE risk assessment documented
% with prophylaxis or contraindication within 24 hrs
% using standardized order set
% receiving pharmacologic prophylaxis, mechanical
prophylaxis
% adherence to mechanical prophylaxis
Different Types of Metrics in
VTE Prevention Efforts
• Outcomes
• # of patients with Hospital-Acquired VTE (HA VTE)
• Rate of HA VTE per 1000 days or 1000 discharges
• % of HA VTE that were potentially preventable
• Balancing Measures
• Bleeding incidence
• Heparin-induced Thrombocytopenia incidence
• Cost (Savings)
Maynard G, Stein J. Agency for Healthcare Research and Quality. August 2008.
VTE Prophylaxis Audits
Assessing Prevalence of
Adequate VTE Prophylaxis
• Order set use
• Detailed audits based on your protocol
• Less detailed audits
• (Red / Yellow / Green strategy)
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Analyze Care Delivery: Delivering Appropriate VTE Prophylaxis
Patient admitted to hospital
30% of failures
35% of failures
MD orders appropriate VTE
prophylaxis at admission
MD links patient’s VTE
risk level to menu of
appropriate VTE
prophylaxis options
MD performs VTE risk
assessment
Pharmacy dispenses and delivers drug
Nurse ensures VTE
prophylaxis administered
Central Supply delivers sequential compression
devices or graduated compression stockings
Support staff ambulates patient 3X/day
Change in patient’s VTE risk
level, contraindications, or
site/unit of care
Patient discharged
VTE prophylaxis can be
complicated!
15% of failures
20% of failures
Mean Baseline Performance: 50%
(% of patients on appropriate VTE
prophylaxis in the hospital)
Maynard G, Stein J. Agency for Healthcare Research and
Quality. August 2008. URL in ref list.
Is your VTE order set in
competition?
VTE Protocol Key Principles
1.
2.
3.
4.
5.
Keep protocol simple to access and use
Don’t interrupt the workflow
Design reliability into the new process
Monitor use of your protocol
Allow for variation from the protocol based on
patient characteristics (rather than providers)
- improve protocol based on feedback and justifiable
variation
6. Fail faster (pilot small scale w/ongoing feedback &
refinement before wider implementation)
Too Little Guidance
Prompt ≠ Protocol
DVT PROPHYLAXIS ORDERS
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Anti thromboembolism Stockings
Sequential Compression Devices
UFH 5000 units SubQ q 12 hours
UFH 5000 units SubQ q 8 hours
LMWH (Enoxaparin) 40 mg SubQ q day
LMWH (Enoxaparin) 30 mg SubQ q 12 hours
No Prophylaxis, Ambulate
VTE Prophylaxis: 3 Patient Groups
Low risk
Moderate risk
High risk
Geerts WH et al. Chest. 2008; 133(6 suppl):381S-453S.
Simplifying Thromboprophylaxis
Patient Group
Prophylaxis
Duration
Medical
LMWH or UFH
Discharge
General surgical
LMWH or UFH
Discharge
Orthopedics
LMWH
25 days
Rivaroxaban plus mech 15 days
Trauma / SCI
LMWH
plus mech Rehab discharge
ICU
LMWH
plus mech discharge
High bleeding risk
Mechanical until risk diminishes, then LMWH
Validated Risk Scoring Systems
University of California San Diego
– Retrospective analysis
– Three-tier risk assessment model (RAM)
– Predicts Risk
– Validated in actual use
Maynard GA et al. J Hosp Med. 2010; 5:10-8.
UCSD
VTE Protocol Validated
• Easy to use, on direct observation – a few seconds
• Inter-observer agreement –
–150 patients, 5 observers- Kappa 0.8 and 0.9
• Predictive of VTE
• Implementation = high levels of VTE prophylaxis
–From 50% to sustained 98% adequate prophylaxis
–Rates determined by over 2,900 random sample audits
• Safe – no discernible increase in HIT or bleeding
• Effective – 40% reduction in HA VTE
–86% reduction in risk of preventable VTE
J Hosp Med 2010 Jan:5(1):10-18.
J Hosp Med 2010 Jan:5(1):10-18.
N = 2,944
mean 82 audits / month
Order Set Implementation
& Adjustment
Baseline
Real time ID &
intervention
Consensus
building
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Level 5
Oversights identified and addressed in real time
95+%
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High Reliability Principles
• Standardize VTE and anticoagulation risk
assessment into the process of admission
and transfers
• “Opt out” of default choices (not opt in)
• Prompts for VTE risk assessment at pointof-care
• Scheduled reassessments
• Redundant responsibility and prompts
Strategies to Improve
Prophylaxis Rates
• BASIC INTERVENTIONS
• In-services
• Newsletters
• Quality improvement presentations
Dobesh PP et al. J Manag Care Pharm. 2005; 11:755-62.
Optimize Strategies for
Effective VTE Prevention
• Alert Systems
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• Electronic alerts (E-alerts)
• Human alerts
Computerized decision support
Raising situational awareness
Audit and feedback
Measure-vention
MEASURE-VENTION
Daily measurement drives concurrent
intervention
Identify patients not receiving VTE prophylaxis in
real time
Ongoing assessment, creates data, reports
data
Use for real-time intervention
Map to Reach Level 5
Situational Awareness and Measure-vention
• Identify patients not receiving anticoagulation
• Empower nurses to place SCDs on these patients as
standing order (if no contraindications)
• Contact MD when patients are not receiving
anticoagulant with no obvious contraindication
• Template note, ‘text’ page, etc.
• Administration to support these interventions with
clear message that physicians should not “shoot the
messenger”
SCDs = sequential compression devices
Map to Reach Level 5
95+ % Prophylaxis
Use Medication Administration Record (MAR) or
automated reports to classify all patients in one of three
zones:
GREEN ZONE
receiving anticoagulation
YELLOW ZONE
receiving mechanical prophylaxis only
RED ZONE
receiving no prophylaxis
Act to move patients at risk for VTE out of the RED!
Digging Deeper on “Yellow” Patients
Is patient low risk?
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Ambulating Independently with 0-1 VTE Risk Factors
Expected LOS <48 hours
Minor Surgery with NO VTE Risk Factors
If yes, prophylaxis adequate, if no…..
Obvious contraindication to pharmacologic prophylaxis?
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Active hemorrhage now or within last 3 days
Post operative bleeding concerns
Platelet count < 50,000 Units
INR > 1.8
Known bleeding disorder, post op bleeding high risk
Hgb < 8.0 g/dL
Concern over CNS bleeding (brain or spinal cord surgery in last week, recent
intracranial hemorrhage, proximity in time to epidural insertion or removal, for
example)
– Hypertensive urgency / emergency
– Comfort care only patient
If yes, mechanical prophylaxis alone adequate, if no, prophylaxis inadequate
Mechanical Prophylaxis Compliance
Setting: 722-bed acute care hospital
Method: Prospective observational trial of mechanical VTE prevention compliance
Interventions:
1. Consecutive patients (n=150) were observed twice daily Mon – Fri to ensure
that sequential compression device (SCD) and venous foot pump (VFP) were used
properly
p=<0.001
2. Compliance Rate=compliant evaluations/total evaluations
100%
82.0%
80%
73.0%
62.0%
60%
40%
20%
0%
All
ICU
Non-ICU
Piazza G et al. Circulation. 2009; 119:2196-201.
Hierarchy of Reliability
Most hospitals at Level 1 or 2
Predicted Prophylaxis
RATE
Standard order set
Standardize process
LEVEL
1
2
No Protocol- “state of nature”
40%
Decision Support Exists
50%
Doesn’t link to order writing OR
Prompts within orders but no decision support
3
4
5
Protocol Well Integrated
Protocol Enhanced
Alerts,
identification
and mitigation
Oversights identified and addressed in real
time
65-85%
90%
95+%
Maynard G, Stein J. Agency for Healthcare Research and Quality. August 2008.
VTE Prevention Collaboratives Using UCSD Model
Over 250 Hospitals
• Society of Hospital Medicine (SHM)
• AHRQ and Quality Improvement Organizations
• Institute for Healthcare Improvement (IHI) Expedition
• British Columbia Hospital Medicine
• American Society of Healthsystems Pharmacists (ASHP)
•Awards to UCSD, Emory, UNM, Washington DC VA, Blessing
(Quincy IL) and British Columbia based on these strategies (all
members of mentored implementation)
• Effective across variety of settings
– Paper and Computerized / Electronic
– Small and large institutions
– Academic and community
2 Common Questions and Biased
Answers
Q. What is the best VTE risk assessment model?
A.Simple, text based model with only 2-3 layers of
VTE Risk
Q. Who should do the VTE risk assessment?
A.Doctors (via admit transfer order sets), with back
up risk assessment by front line nurses or
pharmacists, focusing on those without
prophylaxis.
Key Points - Recommendations
• VTE Risk Assessment embedded in order sets
• Simple risk stratification schema, based on VTE-risk
groups (2-3 levels of risk should do it)
• Customization for some services is desirable.
• Simple measures for adequate VTE prophylaxis
– More detail on selected patients
• Follow Outcomes
• Work on adherence to ordered prophylaxis
• Use measure-vention to accelerate improvement
• Share information / comparing notes helps
Maynard G, Stein J. Designing and Implementing Effective VTE Prevention
Protocols: Lessons from Collaboratives. J Thromb Thrombolysis 2010
Feb:29(2):159-166.
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The Joint Commission
• VTE-1 Venous Thromboembolism Prophylaxis
• VTE-2 Intensive Care Unit Venous Thromboembolism
Prophylaxis
• VTE-3 Venous Thromboembolism Patients with
Anticoagulation Overlap Therapy
• VTE-4 Venous Thromboembolism Patients Receiving
Unfractionated Heparin with Dosages/Platelet Count
Monitoring by Protocol
• VTE-5 Venous Thromboembolism Discharge
Instructions
• VTE-6 Incidence of Potentially-Preventable Venous
Thromboembolism
http://www.jointcommission.org/assets/1/6/Venous%20Thromboembolism.pdf
The Joint Commission on VTE
Risk Assessment/ Prophylaxis
1. Documentation of VTE risk assessment/prophylaxis
within 24 hr of hospital admission
2. Documentation of VTE risk assessment/prophylaxis
within 24 hr after admission to or transfer to ICU
Treatment
Outcomes
6. Incidence of potentially-preventable venous
thromboembolism
The Joint Commission. Venous thromboembolism (VTE) core measure set.
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Latest guidelines
What’s New in the ACCP Guidelines
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Decrease in 1A recommendations
Orthopedic prophylaxis
Mechanical Prophylaxis
VTE prophylaxis in hospitalized medical patients
Risk Assessment Models, endorsement and
extrapolation
Decrease in 1A
recommendations
Hirsh J, Guyatt G, Lewis SZ. Chest. 2008 Jun;133(6):1293-5. PMID: 18574282
Guyatt GH. Chest. 2012 Feb;141(2 Suppl):48S-52S. PMID: 22315255
Decrease in 1A recommendations
Weak recommendations replacing strong
recommendations
WHY?
• More critical look at the evidence, “symptomatic
DVT vs asymptomatic”
• recognition of variability in values and preferences.
• the endorsement of > 80% of panelists to make a
strong recommendation required.
• the exclusion of conflicted experts
Guyatt GH. Chest. 2012 Feb;141(2 Suppl):48S-52S. PMID: 22315255
• “Relying on the perspective of
unconflicted methodologists, rigorously
applying the GRADE approach, and
excluding those with financial and
intellectual conflict of interests from
bottom-line decisions regarding the
quality of evidence and strength of
recommendations led to re-evaluations
of previously existing evidence” Page
50S
What’s New in the ACCP Guidelines
Decrease in 1A recommendations
Orthopedic prophylaxis
Mechanical Prophylaxis
VTE prophylaxis in hospitalized medical patients
Risk Assessment Models, endorsement and
extrapolation
2012 ACCP Guideline
2.1.1 pts undergoing THA or TKA
We recommend use of one of the following for 10-14
days rather than no anti-thrombotic prophylaxis:
LMWH, fondaprinux, apixaban, dabigatran,
rivaroxaban, LDUH, VKA, ASA(all grade 1b), or an
intermittent IPCD(Grade 1c)
THA/TKA=Total Hip or Knee Arthroplasty
IPCD=intermittent pneumatic compression device
LDUH=low dose unfractionated heparin
VKA=Vitamin K Antagonist-warfarin
LMWH=low molecular weight heparin
2012 ACCP Guideline
2.3.1. In patients undergoing THA or TKA, irrespective
of the concomitant use of an IPCD or length of
treatment, we suggest the use of LMWH in preference
to the other agents we have recommended as
alternatives: fondaparinux, apixaban, dabigatran,
rivaroxaban, LDUH (all Grade 2B) , adjusted-dose VKA,
or aspirin (all Grade 2C)
Allow ASA as a choice (split decision)
Allows IPC as stand alone option (with caveats)
ASA?
• 2008 ACCP: recommend against LDUH, ASA
as sole method, with others getting 1a
recommendation, for THR/TKR
• 2007 AAOS: PE prevention
– Standard risk for PE and major bleeding pts should
receive ASA, LMWH, fondaparinux, warfarin. With
concurrent mechanical
• 2011 AAOS: more general
– “we suggest the use of pharmacological agents
and/or compressive device for the prevention of VTE
in pts with elective THR/TKR”
ASA
• There is evidence ASA works, recommend better
than nothing. Suggest LMWH in preference to others
• Don’t use ASA for high risk pts
What’s New in the ACCP Guidelines
• Decrease in 1A recommendations
• Orthopedic prophylaxis
• Mechanical Prophylaxis
• VTE prophylaxis in hospitalized medical
patients
• Risk Assessment Models, endorsement and
extrapolation
ACCP endorses a specific SCD type as stand alone
Joe Cummings, PhD, manager UHC Technology Assessment Group
What’s New in the ACCP Guidelines
• Decrease in 1A recommendations
• Orthopedic prophylaxis
• Mechanical Prophylaxis
• VTE prophylaxis in hospitalized medical
patients
• Risk Assessment Models, endorsement and
extrapolation
Medical prophylaxis
2012 ACCP
2008 ACCP
2.3. For acutely ill hospitalized medical
patients at increased risk of
thrombosis, we recommend
anticoagulant thromboprophylaxis with
LMWH, UFH or fondaparinux (Grade
1B)
6.0.1. For acutely ill medical patients
admitted to hospital with congestive
heart failure or severe respiratory
disease, or who are confined to bed
and have one or more additional risk
factors, including active cancer,
previous VTE, sepsis, acute neurologic
disease, or inflammatory bowel
disease, we recommend
thromboprophylaxis with LMWH
(Grade 1A), LDUH (Grade 1A), or
fondaparinux (Grade 1A)
2.4. For acutely ill hospitalized medical
patients at low risk of thrombosis, we
recommend against the use of
pharmacologic prophylaxis or
mechanical prophylaxis (Grade 1B) .
What’s New in the ACCP Guidelines
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•
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Decrease in 1A recommendations
Orthopedic prophylaxis
Mechanical Prophylaxis
VTE prophylaxis in hospitalized medical patients
Risk Assessment Models, endorsement and
extrapolation
Patients Undergoing General, GI, Urologic, Gynecologic, Bariatric,
Vascular, Plastic, or Reconstructive Surgery
For general and abdominal-pelvic surgery patients at moderate
risk for VTE (~ 3.0%; Rogers score, > 10; Caprini score, 3-4)
who are not at high risk for major bleeding complications, we
suggest LMWH (Grade 2B), LDUH (Grade 2B), or mechanical
prophylaxis, preferably with IPC (Grade 2C), over no
prophylaxis.
Remarks: Three of the seven authors favored a strong (Grade 1B)
recommendation in favor of LMWH or LDUH over no prophylaxis
in this group.
Rogers and Caprini Models in
Surgical Patients
• Endorsed by ACCP
• Acknowledged that Rogers method is not practical
• Caprini model said to be fairly easy to use
– Collaborative improvement experience indicates
otherwise!!!!
• No mention of “3 bucket model”
• Caprini model validation study ----only 10% at level
very low, low risk that do not require AC
Bahl et al Ann Surg 2009
% of Surgical Patients
in Each Risk Category
Low Risk -
0.9%
Moderate Risk - 10.4%
High Risk
-
36.5%
Highest Risk - 52.1%
New Guidelines: Comments / Insights /
Implications
• Controversial guidelines notable for lack of practical
guidance
• Seemingly, one set of biased assumptions has been
replaced by another, skewed in opposite direction
• Recommended risk models cumbersome
• Recommended risk models relatively untested in terms
of inter-observer agreement and efficacy
• Dozens in collaboratives have replicated UCSD
results….fewer VTE, no increase in bleeding
• Valid points: Some inpatients not at significant risk,
attention to possible over anticoagulation is warranted.
• Carve outs? CABG patients reasonable
• Ortho-----depends on your local culture
Other pearls
Recent ACP guidelines
Extended prophylaxis
New agents
ACP guideline
• Risk assessment needed for medical
patients(thromboembolism and bleeding
risk)
• Pharmacologic prophylaxis with heparin or
related drug for VTE in medical (stroke)
patients
• Avoid universal prophylaxis policies
Extended Prophylaxis
• Cancer surgery: 4 weeks
• 2008 ACCP
• THR: 10 days to 35 days
• 2007 AAOS
• ASA up to 6 weeks
• LMWH: 7-12 days
• Warfarin 2-6 weeks
• 2011 AAOS
• Unable to make recommendations
• 2012 ACCP
• 10-14 days orthopedic, hip fracture, THR/TKR
• Up to 35 days
Patients Undergoing General, GI, Urologic, Gynecologic,
Bariatric, Vascular, Plastic, or Reconstructive Surgery
For high-VTE-risk patients undergoing abdominal or pelvic
surgery for cancer who are not otherwise at high risk for major
bleeding complications, we recommend extended-duration
pharmacologic prophylaxis (4 weeks) with LMWH
over limited-duration prophylaxis (Grade 1B).
Remarks: Patients who place a high value on minimizing out-ofpocket health-care costs might prefer limited-duration over
extended-duration prophylaxis in settings where the cost of
extended-duration prophylaxis is borne by the patient.
Patients Undergoing Major Orthopedic Surgery: Total Hip
Arthroplasty (THA), Total Knee Arthroplasty (TKA), Hip
Fracture Surgery (HFS)
In patients undergoing hip fracture surgery (HFS), we
recommend use of one of the following rather than no
antithrombotic prophylaxis for a minimum of 10 to 14 days:
LMWH, fondaparinux, LDUH, adjusted-dose VKA, aspirin (all
Grade 1B), or an IPCD (Grade 1C).
Remarks: We recommend the use of only portable, battery-powered devices
capable of recording and reporting proper wear time on a daily basis for inpatients
and outpatients. Efforts should be made to achieve 18 h of daily compliance. One
panel member believed strongly that aspirin alone should not be included as an
option.
Patients Undergoing Major Orthopedic Surgery: Total Hip
Arthroplasty (THA), Total Knee Arthroplasty (TKA), Hip
Fracture Surgery (HFS)
For patients undergoing major orthopedic surgery, we suggest
extending thromboprophylaxis in the outpatient period for up
to 35 days from the day of surgery rather than for only 10 to 14
days (Grade 2B).
NEWER AGENTS
Oral agents
Study
Record 1
Agent
Rivaroxaban
10mg Daily
initation
After surgery
length
31-39 d
10-14 d
28-35 d
comparison
Enoxaparin
40
Enoxaparin
40
Enox 30 BID Enox 40
Enox 30 BID
N
4541
2531
3494
2101
3195
Procedure
THR
TKR
THR
TKR
TKR
Oral agent
VTE
1.1%
9.6%
6%, 8.6%
36.4%, 40.5% 9%
18.9%
6.7%
37.7%
Comparison 3.7%
VTE
Record 3
RE-NOVATE RE-MODEL
ADVANCE 1
Dabigatran
150mg or
220mg daily
Apixaban
2.5mg BID
6-10 d
10-14d
8.8%
Bottom line
• VTE prevention: safe/effective/cost effective
• Do Risk assessment/Bleeding assessment
• Quality Improvement team, using deliberate
QI strategy
• High reliability strategies: “measure-vention”
• Avoid “mechanical only” in pts at risk and
have no CI to pharmacological
Thanks!
[email protected]