Preventing Hospital-Associated Venous Thromboembolism
Appendix A: Tools and Resources
Table of Contents
Hospitalized patients are at high risk for venous thromboembolism (VTE).
- Pulmonary embolism (PE) and deep vein thrombosis (DVT), collectively known as venous thromboembolism (VTE), represent a major public health problem, affecting 350,000 to 600,000 Americans annually.1
- VTE is primarily a problem among hospitalized and recently hospitalized patients.2,3
- In a large registry trial capturing more than 5,451 patients at 183 sites over a 6-month period, 50 percent (2,726) developed their VTE during hospitalization.4
- Most hospitalized patients have at least one risk factor for VTE.5
- In the absence of prophylaxis, the great majority of inpatient surgical patients have a risk of VTE of at least 3 percent, with many having a much higher risk.6,7
- The high incidence of postoperative VTE and the availability of effective methods of prevention mandate that thromboprophylaxis be considered in every patient.6
- Many medical patients are also at high risk. Medical patients account for approximately half of all hospital-associated VTE events (based on their greater numbers and subpopulations at high risk). Hospitalized medical patients with DVT are more likely to develop PE and fatal PE than their surgical counterparts. 3,4, 8,9 In the DVT FREE Registry study, half the inpatients who suffered from VTE were nonsurgical and had no surgical procedures in the preceding 3 months.4
Venous thromboembolism leads to substantial inpatient costs, morbidity, and mortality.
- The Surgeon General reports up to 200,000 deaths annually related to VTE. This is more deaths than those from breast cancer, AIDS, and traffic accidents combined.1
- Many of these VTE deaths contribute to mortality in the hospital or posthospital period. PE is among the most common preventable causes of mortality associated with hospital stays.10-12
- Symptomatic DVT and PE are associated with high (10-15 percent) fatality rates and extended hospital stays.1 The association with high mortality is partly from the comorbidities accompanying VTE and partly from the VTE itself.
- Treatment for VTE generally requires therapeutic anticoagulation for a minimum of 3 months, which entails inconvenience, cost, and a risk of major or fatal bleeding.13-15
- More than 20 percent of patients with hospital-associated VTE will suffer a recurrent event once anticoagulation has been discontinued, with all the mortality and morbidity that entails.16
- Between 30 and 50 percent of DVT patients develop painful post-thrombotic syndrome.17
- Between 0.5 and 4 percent of PE patients develop chronic thromboembolic pulmonary hypertension.18-20
- Patients and their families relay powerful personal stories related to loss of function, difficulty with anticoagulant therapy, fiscal burden, and fear of recurrence.
- Each hospital-associated DVT represents an incremental cost of $7,700 to $10,800, while each PE represents $9,500 to $16,600 in additional cost.21
- Acute and longer term costs are estimated at $5 billion to $20 billion per year in the United States alone.22
- The Centers for Medicare & Medicaid Services no longer reimburses for the incremental costs of VTE related to some major orthopedic surgeries.23
Effective, safe, and cost-effective measures to prevent hospital-associated VTE exist.
- Pharmacologic prophylaxis reduces the incidence of asymptomatic and symptomatic DVT and PE by 30 to 65 percent.5,24
- The chief concern of prophylaxis is bleeding; bleeding secondary to pharmacologic prophylaxis in patients with limited bleeding risk factors is a relatively rare event, based on abundant data from meta-analyses and placebo-controlled randomized controlled trials.5,25
- Good evidence reveals that pharmacologic VTE prophylaxis for at-risk patients not only prevents adverse patient outcomes but also is cost effective.5,21
A gap between current practice and optimal practice exists.
- The high prevalence of hospital-associated VTE (HA-VTE) is sometimes due to the underutilization of simple, cost-effective prophylactic measures. Of the 2,726 patients in the DVT FREE Registry who had their DVT diagnosed while hospitalized, only 1,147 (42 percent) received prophylaxis within the 30 days before diagnosis.4
- Several prominent organizations acknowledge the magnitude of this "implementation gap":
- The AHRQ report, Making Health Care Safer (archived at http://www.ncbi.nlm.nih.gov/books/NBK26966/), cites the provision of VTE prophylaxis as the paramount effective strategy to improve patient safety, and a 2013 update continues to list improved prophylaxis for VTE as a top 10 patient safety strategy to act on now.26
- The American Public Health Association (APHA) recommends that physicians and other health care providers be aware of risk factors and different risk stratification approaches. APHA adds that they must take more aggressive action in screening patients for risk factors and in prescribing preventive interventions.
- The U.S. Surgeon General produced a call to action document for VTE prevention in 2008 in recognition of VTE as a potentially preventable condition that poses a public health problem.1
VTE prevention is incorporated into public reporting, medical guidelines, Federal regulations, and national quality initiative priorities.
- The National Quality Forum and The Joint Commission have measures regarding VTE Prevention, and these VTE measures recently became mandated core measures in the inpatient setting.27,28
- VTE prevention was one of the focus areas of Partnership for Patients, a major effort from the Centers for Medicare & Medicaid Services to foster accelerated improvement.29
- The Surgical Care Improvement Project has widely used measures for VTE prevention.30
- Hospital-associated VTE is now open to public reporting. The public has an expectation that hospitals will keep them safe. At the same time, there is a growing perception that they are not safe.31
- Having a VTE prophylaxis protocol in place and ensuring that it is followed reduces hospital and governing board liability exposure while improving patient safety.31
Reliably preventing VTE in the hospital is inherently complex.
- VTE risk and bleeding risks vary within patient populations.
- The risk of VTE and the risk of bleeding may change for individual patients several times as they progress through their hospital stay.
- Medication changes, weight, age, renal function, and recent or impending invasive interventions may all influence decisions about the best VTE prevention options.
- Transitions across care providers and locations lead to multiple opportunities for breakdown in the delivery of optimal VTE prophylaxis.
- Thoughtful, evidence-based protocols, multidisciplinary system changes, and comprehensive educational efforts are required to achieve optimal VTE prophylaxis in the complex hospital setting.32,33
Essential elements are needed for effective and safe prevention of VTE in the hospital.
- Educational and awareness efforts alone have proven inadequate in increasing appropriate use of VTE prophylaxis. Similarly, order sets and critical pathways not supported by a healthy quality improvement framework are unlikely to succeed. Process redesign and continuous attention should include these essential elements:
- Selection of a risk assessment model that is best suited for your institution and accepted by treating physicians and other health care practitioners.
- Standardization of VTE risk assessment embedded in well-designed order sets, with each level of VTE risk tightly linked to institutionally endorsed prophylaxis options.
- The VTE prevention order sets need to be used to be effective and should be positioned in such a way that they “touch” virtually all patients at critical junctures (e.g., admission to the hospital, admission or transfer to the critical care unit, changes in level of care, and perioperatively).
- Ongoing monitoring and measurement, coupled with real-time intervention, to ensure that patients on inadequate prophylaxis are identified early and actions are taken to correct oversights and errors proactively.32,33
A roadmap is in place.
- Extensive guidance is available from the literature and consensus conferences.
- AHRQ has produced a comprehensive guide to effective implementation of VTE prevention programs, using a proven performance improvement framework, firsthand experience, and the collective wisdom from hundreds of institutions addressing VTE prevention.
Summary—Push for Support:
- Hospital-associated VTE is an important issue. Effective, safe, and evidence-based measures to prevent HA-VTE are currently underused at many medical centers, resulting in needless mortality and morbidity.
- Personnel who are ready to aggressively address this issue are needed to reduce the prevalence of hospital-associated VTE. A number of guides are available to help them achieve their goals.
- Administrative support for an empowered team is needed.
- Institutional prioritization and the will to standardize and improve systems in the face of substantial cultural and complex barriers is an absolute necessity to achieve breakthrough levels of improvement.
- Improved data collection and reporting, incremental monitoring, creation of metrics, and improved documentation are needed.
- Depending on how advanced or ambitious the effort, it may be important for the team to lay out a business plan, including specific aims, a timeline, personnel, full-time equivalent support, and other required resources.
- U.S. Department of Health and Human Services. Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism. 2008. Available at: http://www.ncbi.nlm.nih.gov/books/NBK44178/. Last accessed January 29, 2013.
- Heit JA, Melton LJ, Lohse CM, et al. Incidence of venous thromboembolism in hospitalized patients vs.community residents. Mayo Clin Proc 2001;76:1102-10.
- Heit JA, Silverstein MD, Mohr DN , Petterson TM, O’Fallon WM , Melton LJ III. Risk factors for deep vein thrombosis and pulmonary embolism: a population-based case-control study. Arch Intern Med 2000; 160(6):809-815.
- Goldhaber SZ, Tapson VF. A prospective registry of 5,451 patients with ultrasound-confirmed deep vein thrombosis. Am J Cardiol 2004;93:259-62.
- Geerts WH, Bergqvist D, Pineo GF et al. Prevention of Venous Thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest June 2008 133:6 suppl 381S-453S
- Gould MK, Garcia DA, Wren SM et al. Prevention of VTE in Nonorthopedic Surgical Patients. Chest February 2012 141:2 suppl e227S-e277S
- Bahl V, Hsou MH, Henke PK, Wakefield TW, Campbell DA, Caprini JA. A Validation of a Retrospective Venous Thromboembolism Risk Scoring Method. Ann Surg 2010;251(2):344-50.
- Goldhaber SZ, Dunn K, MacDougall RC. New onset of venous thromboembolism among hospitalized patients at Brigham and Women’s Hospital is caused more often by prophylaxis failure than by withholding treatment. Chest 2000;118(6):1680-1684.
- Piazza G, Seddighzadeh A, Goldhaber SZ. Double Trouble for 2,609 hospitalized medical patients who developed deep vein thrombosis: prophylaxis omitted more often and pulmonary embolism more frequent. Chest 2007; 132(2):554-561.
- Heit JA, O’Fallon WM, Petterson TM, Lohse CM, Silverstein MD, Mohr DN, et al., Relative impact of risk factors for deep vein thrombosis and pulmonary embolism. Arch Intern Med 2002; 162:1245-1248.
- Tapson VF, Hyers TM, Waldo AL, Ballard DJ, Becker RC, Caprini JA, et al., Antithrombotic therapy practices in US hospitals in an era of practice guidelines. Arch Intern Med 2005; 165:1458-1464.
- Clagett GP, Anderson FA Jr, Heit J, Levine MN, Wheeler HB, Prevention of venous thromboembolism. Chest 1995; 108:312S-334S.
- EINSTEIN Investigators, Bauersachs R, Berkowitz SD, Brenner B, Buller HR, Decousus H, et al. Oral rivaroxaban for symptomatic venous thromboembolism. N Engl J Med 2010; Dec 23;363(26):2499-510.
- EINSTEIN-PE Investigators, Buller HR, Prins MH, Lensin AW, Decousus H, Jacobson BF, et al. Oral rivaroxaban for the treatment of symptomatic pulmonary embolism. N Engl J Med 2012; Apr 5;366(14):1287-97.
- Levi M, Hovingh GK, Cannegieter SC, Vermeulen M, Buller HR, Rosendaal FR. Bleeding in patients receiving vitamin K antagonists who would have been excluded from trials on which the indication for anticoagulation was based. Blood 2008; May 1;111(9):4471-6.
- Prandoni P, Noventa F, Ghirarduzzi A, Pengo V, Bernardi E, Pesavento R, et al. The risk of recurrent venous thromboembolism after discontinuing anticoagulation in patients with acute proximal deep vein thrombosis or pulmonary embolism. A prospective cohort study in 1,626 patients. Haematologica 2007; Feb;92(2):199-205.
- Kahn SR. How I treat postthrombotic syndrome. Blood 2009; Nov 19;114(21):4624-31.
- Pengo V, Lensing AW, Prins MH, Marchiori A, Davidson BL, Tiozzo F, et al. Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism. N Engl J Med 2004; May 27;350(22):2257-64.
- Dentali F, Donadini M, Gianni M, Bertolini A, Squizzato A, Venco A, et al. Incidence of chronic pulmonary hypertension in patients with previous pulmonary embolism. Thromb Res 2009; 124(3): 256-8.
- Poli D, Miniati M. The incidence of recurrent venous thromboembolism and chronic thromboembolic pulmonary hypertension following a first episode of pulmonary embolism. Curr Opin Pulm Med 2011; 17(5): 392-7.
- Dobesh PP. Economic burden of venous thromboembolism in hospitalized patients. Pharmacotherapy 2009;29(8):943-53.
- Mahan CE, Borrego ME, Woersching AL, Federici R, Downey R, Tiongson J, et al. Venous thromboembolism: Annualised United States models for total, hospital-acquired and preventable costs utilising long-term attack rates. Thromb Haemost 2012; Jul 25;108(2):291-302.
- Centers from Medicare & Medicaid Services, Center for Medicare and Medicaid Innovation. Partnership for Patients. Accessed December 10, 2012. http://www.innovations.cms.gov/initiatives/Partnership-for-Patients/index.html.
- Dentali F, Douketis JD, Gianni M, Lim W, Crowther MA. Meta-analysis: anticoagulant prophylaxis to prevent symptomatic venous thromboembolism in hospitalized medical patients. Ann Intern Med 2007; Feb 20;146(4):278-88.
- Shojania KG, McDonald KM, Wachter RM, Owens DK. Closing The Quality Gap: A Critical Analysis of Quality Improvement Strategies, Volume 1—Series Overview and Methodology. Technical Review 9 (Contract No. 290-02-0017 to the Stanford University–University of California, San Francisco, Evidence-based Practices Center). AHRQ Publication No. 04-0051-1. Rockville, MD: Agency for Healthcare Research and Quality. August 2004. Accessed February 1, 2012: http://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/evidence-based-reports/qualgap1.pdf (1.2 MB).
- Shekelle PG, Pronovost PJ, Wachter RM, McDonald KM, Schoelles K, Dy SM et al. The Top Patient Safety Strategies That Can Be Encouraged for Adoption Now. Ann Int Med 2013;158:365-8.
- National Quality Forum. National Voluntary Consensus Standards for Prevention and Care of Venous Thromboembolism: Policy, Preferred Practices, and Initial Performance Measures. Available at http://www.qualityforum.org/Publications/2006/12/National_Voluntary_Consensus_Standards_for_Prevention_and_Care_of_Venous_Thromboembolism__Policy,_Preferred_Practices,_and_Initial_Performance_Measures.aspx. Accessed June 14, 2012.
- Venous Thromboembolism. Available at https://www.jointcommission.org/venous_thromboembolism/. Accessed June 14, 2012.
- Centers from Medicare & Medicaid Services, Center for Medicare and Medicaid Innovation. Partnership for Patients. Accessed December 10, 2012. http://www.innovations.cms.gov/initiatives/Partnership-for-Patients/index.html.
- Medicare Quality Improvement Committee. SCIP Project Information.
- Health Services Advisory Group. Venous Thromboembolism Guide for Executive Leadership. Translating VTE Guidelines Into Practice.
- Maynard G, Morris T, Jenkins I, Stone S, Lee J, Renvall M, Fink E, Schoenhaus R. Optimizing prevention of hospital acquired venous thromboembolism: prospective validation of a VTE risk assessment model. J Hosp Med 2010 Jan:5(1):10-18.
- Maynard G, Stein J. Designing and Implementing Effective VTE Prevention Protocols: Lessons from Collaboratives. J Thromb Thrombolysis 2010 Feb:29(2):159-166.
Please answer the following questions completely but succinctly. Your entire team should assist in this process. “Unknown,” “None,” or “Not Applicable” responses are permissible, but be sure your entire team agrees before resorting to one of these responses. If submitting electronically, you can highlight or bold the most appropriate response.
How many adult medical/surgical beds do you have in your hospital?
- 500 or more
How would you describe your medical center?
- Academic teaching/university
- Community teaching
- Community, nonteaching, no residency programs
- Critical access
What percentage of adult medical patients are seen by hospitalists?
What percentage of adult surgical patients are seen by hospitalists?
Describe your current inpatient health record
- All electronic (documentation, lab review, and orders)
- All paper
- Hybrid (electronic documentation and lab review, but orders on paper)
If you have an electronic health record, please record the type/version below (example: Cerner, Epic):
Sponsorship and support from the medical center, specifically from key leaders, are absolutely essential. Basics, such as revisions to order sets, data collection resources, or tweaks of a health information system, may require special permission, fast-track approval processes, or dedicated personnel. While most obstacles will merely require patience or ingenuity, some may be insurmountable without the influence of executive leadership.
Rate your institutional support on a 1 to 5 rating scale on the following parameters, with 5 representing the best possible support and 1 representing a lack of awareness or meaningful support.
- The will and means to standardize the approach to VTE prevention, the VTE prevention components in order sets, and broad use of protocol-driven order sets.
1 2 3 4 5
- The prioritization of the project, as manifested by the existence of a dedicated VTE prevention team, reporting of the VTE prevention steering group through executive medical staff and administrative committees, incentives for the administration based on VTE prophylaxis use, extra physician time or money allocated to leading the initiative, and extra resources to track VTE prophylaxis rates and hospital-associated VTE rates.
1 2 3 4 5
The team leader should be a clinician the medical staff respects and, ideally, have some topic expertise on VTE prophylaxis and anticoagulation. The team leader is responsible for setting the agenda, the frequency, and the collaborative tone of team meetings, and for communicating directly with administrative and medical staff committees.
What are the strengths / skills that the team leader brings to this initiative?
The team leader needs commitment and contributions from other team members to move the initiative forward. The team leader and the team may need to recruit local champions based on service or hospital geography. For example, a pulmonary or critical care physician may lead efforts on VTE prophylaxis in the ICUs while a hospitalist may lead efforts on the floors or wards. Whatever the format, a coordinated effort is required across the entire spectrum of care. Frontline personnel involved in the process of providing VTE prophylaxis in the hospital are essential for an effective team wishing to optimize VTE prevention. To track the effectiveness of your quality improvement interventions, the contributions of information technology or health information system experts are pivotal.
Please list the team members you currently have. If you have no team members meeting these descriptions, just fill in as not applicable (N/A). Comments on special roles, type of work (e.g., critical care vs. ward), or degree of involvement can be made under “Role.”
Physician Name (1):
Department and Role (Hospitalist? Employed by med center or independent? Area of influence?)
Physician Name (2):
Department and Role:
Physician Name (3):
Department and Role:
Quality/Management Department (1):
Quality/Management Department (2):
Executive from the C-suite…administrative liaison and administrative champion:
Nursing Leadership members (1):
Nursing Leadership members (2):
Front Line nursing representative (1):
Front Line nursing representative (2):
IT/data collection or management (1):
IT/data collection or management (2):
Computerized physician order entry and Electronic Health Record representative:
Looking at your team, what additional strengths do the members of the team bring (beyond what the team leader possesses)?
Looking at your team, what gaps in expertise, influence, or perspective exist? Do you have all the key players on your team? If not, who else should be invited?
Prior and Ongoing Efforts
Does your institution have any ongoing method or past efforts to improve VTE prevention? Examples might include the Surgical Care Improvement Project, The Joint Commission, or National Quality Forum core measures for VTE prevention, participation in a past collaborative, or attempts to standardize protocol-driven order sets. Review your performance for VTE-related measures at Hospital Compare (http://www.medicare.gov/hospitalcompare/search.html).
How successful do you think these efforts have been in achieving near-perfect VTE prophylaxis for your inpatients? What barriers, successes, and lessons learned did you gain from these efforts? Are there groups that seem most likely to obstruct improvement efforts, or to champion them?
What performance data on VTE prevention or VTE events already exist or are collected on a routine basis at your institution? Cut and paste pertinent data here or submit a copy of a recent report.
Current VTE prophylaxis rates (estimated or measured):
Incidence of hospital-associated VTE:
Do you have institutional policies or protocols regarding VTE prophylaxis (for nursing or physicians)?
Does your organization currently use VTE prevention order sets or drafts for VTE prevention order sets?
Do you have extended prophylaxis discharge order sets or institutional guidelines regarding extended duration prophylaxis?
Do you have a method to create reports for frontline nurses or pharmacists regarding DVT prophylaxis (e.g., a report outlining all patients on a given ward and what prophylaxis they are on)?
If so, please describe:
Do you have any method for tracking the reliable delivery of ordered VTE prophylaxis (e.g., the percentage of patients with mechanical prophylaxis who actually have the mechanical device on and in place, or the percentage of ordered prophylactic anticoagulant doses that are actually delivered)?
If so, please describe:
Hierarchy of Reliability
Please select the description that most accurately reflects your progress on VTE prophylaxis to date:
- We don’t have a protocol for our institution. We rely on doctors to write in/choose the most appropriate DVT prophylaxis based on their judgment and training.
- Our institution has a protocol for VTE prophylaxis that outlines preferred choices for different situations. However, the protocol guidance is not embedded in order sets. Services may have order sets that include a list of VTE prophylaxis options, but they are offered as equivalent choices and do not reflect guidance from an institutionally endorsed protocol.
- Our institution has a protocol for VTE prophylaxis and protocol guidance embedded in order sets. However, order set utilization/acceptance has been uneven and suboptimal. Many patients get admitted or transferred without being exposed to the potential benefit of our protocol.
- We have an institutionally endorsed protocol-driven VTE prevention order set (or order set module) that is positioned in such a way that it provides guidance to almost every targeted adult medical/surgical patient at the point of admission and at the time of transfer from one level of care or ward to another.
- We meet the criteria for Description No. 4 and we also have other methods to reinforce protocol guidance, such as audit and feedback to providers, checklists incorporating VTE prophylaxis, and a comprehensive educational program.
- We meet the criteria for Description No. 4, and we also monitor prophylaxis on a regular basis, allowing us to correct deficiencies on VTE prophylaxis on a routine (near daily) basis.
Reflect on your team, your institution, the quality improvement infrastructure, and the resources available to you. What do you perceive are the key strengths, weaknesses, opportunities, and threats/barriers to implementing a successful VTE prevention initiative at your institution in the next 6 months? Include issues you’ve already identified in previous sections of this survey instrument. Once you’ve identified all of the critical issues, list them in the appropriate box/section in the table below.
The Sample Aim Statement can be used by leadership to charter a VTE prevention team or to provide direction to an existing team. They can guide the team in organizing a quality improvement project and developing a written, measurable, and time-sensitive description of the accomplishments the team expects from its improvement efforts.
The aim statement answers the question: “What are we trying to accomplish?”
By (Date) , ____ percent of hospitalized patients will receive VTE prophylaxis as defined by hospital-approved protocols and according to a patient’s assessed status of VTE risk or prophylaxis contraindications based on a hospital-approved VTE prophylaxis assessment tool. Contraindications will be clearly documented in the medical record for 100 percent of the cases in which VTE prophylaxis is not ordered.
Definition of an Aim Statement
An aim statement is a written, measurable, and time-sensitive description of the accomplishments the hospital’s VTE team expects to make from its improvement efforts. The aim statement answers the question: “What are we trying to accomplish?”
The aim statement should be developed with input from senior leadership to ensure support for the VTE team and alignment with the strategic goals of the organization. An organization will not improve without a clear and firm intention to do so. The performance goals should represent a challenge for the organization.
Developing an Aim Statement
There is no single correct way to write an aim statement, but most effective aim statements have the following attributes:
- Communicate the expectations.
- Are time-specific.
- Are measurable.
- Define the specific population or populations affected.
- Are clear and unambiguous.
- Are brief and concise.
- Aim big.
Q1. Why should VTE prevention be a priority for our hospital?
VTE is primarily a problem of hospitalized and recently hospitalized patients and is frequently estimated to be among the most common preventable causes of hospital death. Symptomatic VTE is associated with high fatality rates, extended length of hospital stay, post-thrombotic syndrome, and chronic thromboembolic pulmonary hypertension. In-hospital costs and morbidity are high and, once a diagnosis of VTE is made, patients generally require at least 3 months of therapeutic anticoagulation, with all the attendant bleeding risk and inconvenience that implies. A large proportion of hospital-associated VTE (HA-VTE) cases are preventable, and prophylaxis of those at risk is cost-effective. Regulatory measures and fiscal penalties are other pressures for optimizing VTE prevention. (Refer to the Talking Points in this appendix for more information.)
Q2. Our hospital does well on CMS/TJC core measures for VTE prevention and Surgical Care Improvement Program (SCIP) measures. Why can’t we just move on to something else rather than spend time on something we have already "fixed"?
While adherence to the measures is desirable and results in some improvement, the measures actually set a relatively low bar for the quality of VTE prophylaxis. These measures of prophylaxis quality look only at narrow windows in time (within 24 hours of admission to the hospital, or admission or transfer to ICU, or within 24 hours of surgery) versus assessing the quality of prophylaxis across the hospital stay. CMS/TJC measures VTE-1 and VTE-2 do not discern the quality or appropriateness of prophylaxis, but instead equate any prophylaxis with appropriate prophylaxis.
VTE is not considered potentially preventable for patients with any prophylaxis in place before the tests that diagnose VTE are ordered; a patient at high risk for VTE whose only prophylaxis during a 30-day stay was graduated compression stockings on hospital day 24, and who was diagnosed on hospital day 25, would be classified as "not preventable." Adherence to these measures does not address many failure modes that can lead to HA-VTE, such as failure to ambulate the patient, take out unnecessary central venous catheters, and so forth. Better measures are required to assess institutional performance and to inform improvement efforts. (Go to Chapters 6 and 7 for more information.)
Q3.Should every hospitalized patient get VTE prophylaxis?
No. Pharmaco-prophylaxis carries a risk of bleeding and heparin-induced thrombocytopenia, while mechanical prophylaxis can exacerbate skin conditions or vascular insufficiency. Both forms of prophylaxis can be uncomfortable for the patient and take staff time to administer and monitor, and they incur expense. Patient preferences should be taken into account, and not all inpatients have a high enough risk of VTE to warrant the risks and costs associated with prophylaxis. (Go to Chapters 3 and 4 for more information.)
Q4. The 9th edition of the ACCP (AT9) guidelines seem to endorse individualized VTE risk assessment models with point-scoring systems over grouping models. Should we change our VTE risk assessment model and order sets to reflect the Padua model for medical inpatients and the Caprini model for surgical inpatients (since they are mentioned in the guidelines)?
There is no mandate to switch from a risk assessment model that works well for your institution, and not enough evidence to distinguish one type of model as a favorite over another. AT9 does not offer any formal recommendation for VTE risk assessment, although it states a preference for individualized VTE risk assessment and embeds certain risk assessment models in the recommendations. This has been a point of controversy.
Simpler qualitative grouping models that place patients in “buckets” of risk have worked very well in many institutions. Individualized point-scoring methods are attractive in many ways, but they can be difficult to implement or use reliably. The decision about which risk assessment model to use in order sets should only be made after careful consideration of ease of use, sophistication of the informatics and clinical decision support in your health record, evidence for clinical utility, and ability to predict VTE risk (Go to Chapters 4 and 5 for more information).
Q5. Should we screen our asymptomatic patients at high risk for DVT with regular Doppler compression ultrasound testing?
Surveillance screening of asymptomatic patients is controversial. On the plus side, early diagnosis of DVT could conceivably lead to earlier interventions and prevention of PE. However this practice, most commonly deployed on orthopedic and trauma services, is discouraged by AT9 (2C), AT8, ACP1, and AAOS2 guidelines. Many patients who develop a screening-detected DVT will resolve the DVT spontaneously and never have symptoms.
Once discovered, most asymptomatic screening-detected VTEs are treated with therapeutic anticoagulation, with uncertain benefit but well-defined risks of bleeding. Institutions that have surveillance programs will also likely have an increase in the number of VTE cases captured by administrative data and TJC measures. If screening is used, you may want to restrict it to very high-risk patients who cannot be on anticoagulant prophylaxis. (Go to Chapter 3 for more information.)
Q6. How do we prevent upper-extremity DVT (UE DVT)? Does prophylaxis work?
Convincing trials of anticoagulant prophylaxis against symptomatic UE DVT are currently lacking, but a recent meta-analysis found that anticoagulant prophylaxis is effective for preventing all CVC-related DVT, and it seems likely that anticoagulant prophylaxis reduces symptomatic UE DVT to some extent. In any case, most inpatients with a CVC warrant anticoagulant prophylaxis based on cumulative risk factors. The best way to prevent CVC-related UE DVT is to reduce exposure to catheters and, when use is necessary, to adhere to all best practices in insertion and maintenance of the CVC.
One center reported a reduction in PICC-associated DVT from 3.0 percent to 1.9 percent. Interventions included interdisciplinary consensus on the need for each PICC, early PICC removal, assurance of proper placement, use of a PICC with the smallest number of lumens required, and a change to smaller diameter PICCs. (Go to Chapter 7 for more information. See also Maynard G. Upper extremity deep vein thrombosis: a call to arms. JAMA Intern Med. Published online March 17, 2014.)
Q7. I’ve heard about some hospitals monitoring anti-Xa levels to adjust the LMWH dose for VTE prophylaxis. Is this medically or legally necessary?
This practice has become popular in some settings, especially SICU/Trauma/burn patients, and to some degree in morbidly obese and obstetric patients. The evidence is far from definitive, but several studies have revealed that standard dosing often does not lead to desired anti-Xa levels, as well as an association between low anti-Xa levels and the risk of HA-VTE. The strongest work may be in high-DVT-risk trauma patients. In before and after studies, screening-detected DVT were less common in the “after” time period, in which adjustment of LMWH dosing was performed using anti-Xa levels. ACCP guidelines do not mention the practice, perhaps in part because they are now rejecting evidence with screening-detected DVT. This practice seems to be spreading in advance of any randomized trial evidence that it reduces symptomatic VTE safely.
(Go to Chapter 3 for more information. See also Malinoski D, Jafari F, Ewing T, et al. Standard prophylactic enoxaparin dosing leads to inadequate anti-Xa levels and increased deep venous thrombosis rates in critically ill trauma and surgical patients. J Trauma 2010;68(4):874-80; and Costantini TW, Min E, Box K, et al. Dose adjusting enoxaparin is necessary to achieve adequate venous thromboembolism prophylaxis in trauma patients. J Trauma Acute Care Surg 2013;74(1):128-35.)
Q8. Can we use mechanical prophylaxis as a sole agent for prophylaxis?
In nonsurgical patients at risk for VTE, pharmaco-prophylaxis is recommended over no prophylaxis, and mechanical prophylaxis should not be relied on unless there are extenuating circumstances regarding patient preference. Mechanical prophylaxis is a good choice in this population if bleeding risk or other contraindications to heparinoids exist.
In surgical patients, some moderate-risk patients can have either mechanical or pharmaco-prophylaxis, with the caveat that it is difficult to administer mechanical prophylaxis reliably and that pharmaco-prophylaxis has more of a track record. (Go to Chapter 3 for more information.)
Q9. We have graduated compression stockings (GCS) at our hospital but are switching to intermittent pneumatic compression devices (IPCDs). Why switch? Are IPCDs better than GCS for DVT prophylaxis?
There are many forms of mechanical prophylaxis (calf vs. thigh high, GCS vs IPCD, different types of IPCD, some with sequential compression, some with single chambers, and so forth). Until recently there was insufficient evidence to recommend one type of mechanical prophylaxis over another. Evidence is now accumulating that IPCD may be preferable in certain populations, especially stroke patients and select surgical groups. No matter what type of mechanical prophylaxis is used, efforts to ensure these devices are on and in proper position are crucial, with a target of having them on for 18 hours or more per day. (Go to Chapter 3 for more information.)
Q10. What are the indications for placing an inferior vena cava (IVC) filter?
The most widely accepted indication for IVC filter placement is for patients with a DVT who cannot be treated with therapeutic anticoagulation, or failure of anticoagulation with acute proximal venous thromboembolism. IVC filters are sometimes used as a primary form of prophylaxis in patients with very high risk of DVT (multiple major trauma patients, for example) who cannot receive pharmacologic prophylaxis because of bleeding risk. The AT9 guidelines have a low-level (2C) recommendation against it, preferring that mechanical prophylaxis be used until bleeding risk subsides. IVC filters are also sometimes used for patients with limited cardiopulmonary reserve, for whom even a small pulmonary embolism might have dire consequences.
The decision to place an IVC filter should not be taken lightly, as complications such as hematoma, filter fracture and migration, IVC thrombosis, DVT, and filter erosion through the vascular wall have all been reported. There are removable IVC filters, which could conceivably reduce long-term adverse events—but even these filters are most commonly left in place. (Go to Chapter 3 for more information.)
Resources for Clinicians
AHRQ: Venous Thromboembolism Prophylaxis in Orthopedic Surgery based on Comparative Effectiveness Review Number 49. https://effectivehealthcare.ahrq.gov/topics/thromboembolism-update/research-2017
Partnership for Patients/CMS Resources for Venous Thromboembolism: Links to resources for VTE prevention and management. http://partnershipforpatients.cms.gov/p4p_resources/tsp-venusthromboembolism/toolvenousthromboembolismvte.html
Institute for Healthcare Improvement (IHI) VTE Mentor Registry: Sites that have been successful in VTE prevention give case histories and volunteer to help others. http://www.ihi.org/Engage/Memberships/MentorHospitalRegistry/Pages/VenousThromboembolus.aspx
Society of Hospital Medicine Venous Thromboembolism Resource Room. http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_VTE/VTE_Home.cfm
VTE Core Measures Specifications. http://www.jointcommission.org/venous_thromboembolism/
National Hospital Inpatient Quality Measures for VTE. http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures.aspx
Resources for Consumers
AHRQ: Venous Thromboembolism Prophylaxis in Orthopedic Surgery. https://effectivehealthcare.ahrq.gov/topics/blood-clots-hip-knee-surgery/research
CDC DVT/PE tools for patients and professionals. http://www.cdc.gov/ncbddd/dvt/index.html
Page originally created May 2016