Appendix B: Sample Venous Thromboembolism Protocol/Order Set

Preventing Hospital-Acquired Venous Thromboembolism

University of California, San Diego Medical Center VTE Risk Assessment and Prophylaxis Orders
(paper version of computerized order set)

Low Risk	Moderate Risk	High Risk
Ambulatory patient without additional VTE risk factors or expected length of stay <2 days. Minor surgery in patient without additional VTE risk factors (same day surgery or operating room time <30 minutes). * Early ambulation.	Patients who aren't in either the low- or high-risk group (go to VTE risk factor table) *Select one pharmacologic option:** Enoxaparin# 40 mg SQ q 24 hours UFH 5,000 units SQ q 8 hours UFH 5,000 units SQ q 12 hours (use only if wt <50kg or >75 yrs) or No pharmacologic prophylaxis because of contraindication ________________________ (go to Contraindications table below) No pharmacologic prophylaxis because it is optional in this special population (GYN surgery). Sequential compression device aka SCDs (Optional for these patients if they are on pharmacologic prophylaxis, mandatory if not). SCDs to Both lower extremities. Right leg only. Left leg only. Patient intolerant or has skin lesions on both legs, do not use SCDs.	Elective hip or knee arthroplasty. Acute spinal cord injury with paresis. Multiple major trauma . Abdominal or pelvic surgery for cancer. Select one pharmacologic # option: Enoxaparin* 40 mg SQ q 24 hours. Enoxaparin* 30 mg SQ q 12 hours (knee replacement). Warfarin _______mg PO daily, target INR 2-3; hold INR >3. or UFH 5,000 units SQ q 8 hours (only if creatinine clearance is < 30, SCr >2, and warfarin is not an option). No pharmacologic prophylaxis because of contraindication. ________________________ (go to Contraindications table below) and SCDs to Both lower extremities. Right leg only. Left leg only. Patient intolerant or has skin lesions on both legs, do not use SCDs.

Low Risk

Moderate Risk

High Risk

Ambulatory patient without additional VTE risk factors or expected length of stay <2 days.
Minor surgery in patient without additional VTE risk factors (same day surgery or operating room time <30 minutes).

* Early ambulation.

Patients who aren't in either the low- or high-risk group (go to VTE risk factor table)

Select one pharmacologic* option:

Enoxaparin# 40 mg SQ q 24 hours
UFH 5,000 units SQ q 8 hours
UFH 5,000 units SQ q 12 hours (use only if wt <50kg or >75 yrs)

No pharmacologic prophylaxis because of contraindication
________________________
(go to Contraindications table below)
No pharmacologic prophylaxis because it is optional in this special population (GYN surgery).

Sequential compression device aka SCDs (Optional for these patients if they are on pharmacologic prophylaxis, mandatory if not).

SCDs to

Both lower extremities.
Right leg only.
Left leg only.
Patient intolerant or has skin lesions on both legs, do not use SCDs.

Elective hip or knee arthroplasty.
Acute spinal cord injury with paresis.
Multiple major trauma .
Abdominal or pelvic surgery for cancer.

Select one pharmacologic # option:

Enoxaparin* 40 mg SQ q 24 hours.
Enoxaparin* 30 mg SQ q 12 hours (knee replacement).
Warfarin _______mg PO daily, target INR 2-3; hold INR >3.

UFH 5,000 units SQ q 8 hours (only if creatinine clearance is < 30, SCr >2, and warfarin is not an option).
No pharmacologic prophylaxis because of contraindication.
________________________
(go to Contraindications table below)

and

SCDs to

Both lower extremities.
Right leg only.
Left leg only.
Patient intolerant or has skin lesions on both legs, do not use SCDs.

* Go to Contraindications table.
# Enoxaparin should only be used in patients with CrCl>30 and SCr<2; do not use if epidural/spinal catheter is in place.
SCDs should be used in all patients for whom pharmacologic prophylaxis is contraindicated and in all high-risk patients unless patient is intolerant or with contraindications to SCDs.
Note: Enoxaparin is the USCD Medical Center formulary low molecular weight heparin (LMWH); other LMWHs are considered equivalent.

Venous Thromboembolism Risk Factors

Age >50 years
Myeloproliferative disorder
Dehydration
Congestive heart failure
Active malignancy
Hormonal replacement
Moderate to major surgery

Prior history of VTE
Impaired mobility
Inflammatory bowel disease
Active rheumatic disease
Sickle cell disease
Estrogen-based contraceptives
Central venous catheter

Acute or chronic lung disease
Obesity
Known thrombophilic state
Varicose veins/chronic stasis
Recent post-partum with
immobility
Nephrotic syndrome
Myocardial infarction

Contraindications or Other Conditions to Consider With Pharmacologic VTE Prophylaxis

Absolute	Relative	Other Conditions
Active hemorrhage. Severe trauma to head or spinal cord with hemorrhage in the last 4 weeks. Other___________________	Intracranial hemorrhage within last year. Craniotomy within 2 weeks Intraocular surgery within 2 weeks. Gastrointestinal, genitourinary hemorrhage within the last month. Thrombocytopenia (<50K) or coagulopathy (prothrombin time >18 seconds). End stage liver disease. Active intracranial lesions/neoplasms. Hypertensive urgency/emergency. Post-operative bleeding concerns**	Immune mediated heparin-induced thrombocytopenia. Epidural analgesia with spinal catheter (current or planned).

** Scheduled return to OR within the next 24 hours: major ortho: 24 hours leeway; spinal cord or ortho spine: 7 days leeway; general surgery, status post transplant, status post trauma admission: 48 hours leeway.

Current as of August 2008

Internet Citation: Appendix B: Sample Venous Thromboembolism Protocol/Order Set: Preventing Hospital-Acquired Venous Thromboembolism. August 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/vtguide/vtguideapb.html