Venous Thromboembolism
Prophylaxis and
Management in the
Medical Patient at Sisters
of Charity Hospital
Jeffrey Parker, DO
Dr. Nashat Rabadi, MD
Sisters of Charity Hospital
Buffalo, New York
Case Presentation
• Hospital Course
– 60 year old female directly admitted to the
hospital with acute on chronic CHF
– Over the phone orders were given to
nurse by primary doctor
– CHF standardized form not used
– DVT prophylaxis form not used
Case Presentation
• Appropriate CHF treatment given
• Pts symptoms improve
• On third hospital day, patient complains of left calf
pain and increased swelling
• Left DVT diagnosed by venous doppler
• Heparin and Coumadin started
Case Presentation
Why did the patient develop a DVT?
Presentation Overview
• VTE Background
• VTE Prophylaxis and Treatment
• Joint Commission VTE Safety Guidelines
• Research Question and Methods
Venous Thromboembolism
• Deep vein thrombosis (DVT) and acute pulmonary
embolism (PE) are two manifestations of the same
disorder, venous thromboembolism
• Over 90 percent of cases of acute PE are due to
emboli emanating from the proximal veins of the
lower extremities
VTE Morbidity and Mortality
• DVT and PE represent a major health
problem
• Hospitalized patients have a 150-fold
increased absolute risk compared to patients
in the community
• 10% of hospital deaths are due to PE
• In-hospital case-fatality rate of VTE is 12%
VTE Risk Factors
• Age
• Immobilization
• Surgery within the
last three months
• Stroke
• Family history
• History of venous
thromboembolism
• Malignancy
• Preexisting
respiratory disease
• Congestive heart
failure
• Oral contraceptives
VTE Risk Factors
• Nephrotic syndrome
• Inflammatory bowel
disease
• Sepsis
• Hypercoaguable state
• Additional identified in
women:
– Obesity
– Heavy Cigarette
smoking
– Hypertension
• Patients with Idiopathic
PE:
– Factor V Leiden
mutation
– Increased factor VIII
VTE Risk Factors
• The greater the number of risk factors a
person has, the greater risk of
developing a DVT!
VTE Prophylaxis
• Ambulation
• Warfarin
• Arteriovenous foot
pumps
• Unfractionated Heparin (UFH)
• Sequential
compression devices
• Elastic stockings
• Low Molecular Weight Heparin
(LMWH)
• Fondaparinux
• IVC filter
VTE Prophylaxis
The Seventh ACCP Consensus Conference on
Antithrombotic Therapy recommends the use of either
LMWH or low dose unfractionated heparin (LDUH) for
VTE prophylaxis in acutely ill hospitalized patients without
contraindications:
• Congestive heart failure or severe respiratory
disease
• Confined to bed and have ≥1 additional risk factors
• Upon admission to a critical care unit
VTE Prophylaxis - LDUH
• 2007 study done comparing BID vs TID heparin
dosing for VTE prophylaxis in the general medical
population*
• Meta-analysis of 12 randomized controlled studies
comparing BID or TID heparin dosing
• Concluded that TID dosing is likely superior to BID
UFH for VTE prevention in hospitalized medical
patients
•
*King, C, et al. Twice vs Three Times Daily Heparin Dosing for Thromboembolism
Prophylaxis in the General Medical Population.Chest 2007;131;507-516.
VTE Prophylaxis/Treatment Background
• Evidence-based DVT/PE guidelines for prophylaxis
and treatment are not being routinely followed
• High risk patients are not receiving appropriate VTE
prophylaxis
• Patients diagnosed with VTE are not receiving
appropriate treatment
• Occurring at both academic and community hospitals
in the United States
VTE Prophylaxis Background
“…doctors are not doing
enough to prevent DVT
cases.”
VTE Prophylaxis Background
• A prospective registry of 5,451 patients with
ultrasound-confirmed deep vein thrombosis
• Among hospitalized patients who had developed
DVT, only 42% had received prior prophylaxis
despite multiple risk factors, particularly in nonsurgical patients
•
Goldhaber S, Tapson V. A prospective registry of 5,451 patients with ultrasound-confirmed
deep vein thrombosis. The American Journal of Cardiology 2004;93:259-262
Why is Prophylaxis Underused?
• Inconsistencies, conflicts, and ambiguities within the
many different guidelines available
• Some physicians may be unaware of the current
guidelines
• Some physicians may not believe the evidence for the
guidelines is adequate
• Belief that VTE incidence in hospitalized and
postoperative patients is too low to warrant routine
prophylaxis
Why is Prophylaxis Underused? (cont)
• Concern that patients will be at risk for bleeding
complications associated with pharmacologic
prophylaxis
• Concern that patients will be at risk for heparininduced thrombocytopenia (HIT)
• Lack of awareness that broad application of
prophylaxis may be cost-effective
• Perception that VTE is not a significant problem in an
individual physician’s practice
VTE Prophylaxis
• Reliance on symptoms or signs of early DVT
is unreliable strategy to prevent VTE
• Routine screening of patients for
asymptomatic DVT:
– Logistically difficult
– Not cost effective
– Not effective in preventing clinically
important VTE events
Consequences of Inadequate VTE
Prophylaxis
• Increased morbidity and mortality
• Costly diagnostic testing
• Cost of therapeutic anticoagulation therapy
• Potential bleeding complications from
therapy
• Delayed hospital discharge
• Increased future risk of recurrent VTE
VTE Prophylaxis: An Important
Healthcare Priority
• Agency for Healthcare Research and Quality:
– VTE prophylaxis top-ranked evidence-based
safety practice
• National Quality Forum (NQF):
– Top 30 practices to reduce risk
– Evaluate VTE risk, use clinically appropriate
prophylaxis
VTE Prophylaxis: An Important
Healthcare Priority
• Joint Commission designated DVT as one of the
“most common preventable causes of death in
hospitals”
– Estimated 60-70% of patients needing
prophylaxis don’t receive it”
• American College of Chest Physicians
Guidelines
– Gives anticoagulant prophylaxis in medical
patients a grade 1A recommendation
Cost Burden of VTE
DVT and PE diagnosis and treatment costs in the U.S. are estimated to be
as much as $15.5 billion annually
Per Patient Medical Costs
$30,000
$25,554
$17,512
$20,000
$18,901
$10,000
$680
$0
Patient
without DVT
or PE
Patient with
DVT
Patient with Patient with
PE
DVT and PE
MacDougall DA, et. Al. Am J Health-Syst. Pharm. 2006;63(Suppl 6):s5-15
Cundiff DK. Medscape General Medicine. 2004;6(3):5.
Joint Commission
• The following measures
were developed by the
Joint Commission
under the guidance of
NQF’s ‘Prevention and
Care of VTE’ project
and are currently being
pilot tested
Joint Commission VTE Safety Guidelines
1) VTE Risk Assessment/Prophylaxis within 24
hours of Hospital Admission
2) VTE Risk Assessment/Prophylaxis within 24
hours of Transfer to ICU
3) Documentation of Inferior Vena Cava Filter
Indication
4) VTE Patients with Overlap Therapy
Joint Commission VTE Safety Guidelines (cont)
5) VTE Patients Receiving Unfractionated
Heparin with Platelet Count Monitoring
6) VTE Patients Receiving Unfractionated
Heparin Management by
Nomogram/Protocol
7) VTE Discharge Instructions
8) Incidence of Potentially Preventable Hospital
Acquired VTE
VTE Treatment in Hospital
• Initiate treatment with full dose LMWH, UFH,
or fondaparinux for at least 5 days and until
the INR is > 2.0 for 24 h (unless
contraindicated)
• Initiate Coumadin treatment together with
LMWH, UFH, or fondaparinux on the first
treatment day rather than delayed initiation
(unless contraindicated)
• Therapeutic INR of 2 - 3
VTE Treatment in Hospital
• In patients with acute DVT, early
ambulation is preferred to initial bed
rest when this is feasible
• Bridging therapy with LMWH is
indicated
– INR is sub-therapeutic at discharge
– Inadequate overlap therapy
Research Question
• Are high risk patients receiving appropriate
VTE prophylaxis at Sisters Hospital?
• Are the standardized admission order forms
being utilized at Sisters Hospital?
• What diagnostic modalities are being utilized
at Sisters Hospital to diagnose VTE?
Research Question (cont)
• Is the treatment for VTE appropriate at Sisters
of Charity Hospital with regards to:
– Type of anticoagulation
– Complications due to treatment
– Overlap therapy
– Appropriate bridging therapy
– Length of hospital stay
Methods
• Retrospective chart review of patients
diagnosed with and admitted to the
hospital from 1/08 with:
– CHF
– Pneumonia
– Known cancer (lung, colon, ovarian)
Methods (cont)
• Each chart was reviewed for:
– Appropriate DVT prophylaxis
– DVT prophylaxis sheet completed
– Standardized admission forms completed
if applicable
Methods (cont)
• Retrospective chart review of patients
diagnosed with VTE from January 2008 –
present at Sisters of Charity Hospital
Methods (cont)
•
Appropriate treatment
•
Coumadin start date
•
Appropriate overlap
therapy
•
Therapeutic INR at
discharge
•
Family History
•
Complications from
treatment
•
Hypercoaguable
workup done
•
DVT and PE
standardized order
sheets completed
Methods (cont)
• Compare 2006 and 2009 VTE
Prophylaxis and Management Data
Comparison
VTE Prophylaxis Research Data
CHF VTE Prophylaxis
(n = 50)
% of Cases
Number of Cases
UFH Q8
38%
19
LMWH
26%
13
SCD’s
0%
0
Warfarin
22%
11
UFH Q12
4%
2
No Prophylaxis
10%
5
Resident Following
58%
29
DVT Sheet
Complete
58%
29
CHF Sheet
Complete
74%
37
CHF VTE Prophylaxis
14%
Appropriate
Prophylaxis
Inappropriate
Prophylaxis
86%
Pneumonia VTE Prophylaxis
(n = 50)
% of Cases
Number of Cases
UFH Q8
56%
28
LMWH 40mg
14%
8
SCD’s
6%
3
Warfarin
0%
0
UFH Q12
16%
7
No Prophylaxis
14%
7
Resident Following
52%
26
DVT Sheet Complete
44%
22
Pneumonia Sheet
Complete
68%
34
Pneumonia VTE Prophylaxis
30%
Appropriate
Prophylaxis
Inappropriate
Prophylaxis
70%
Malignancy VTE Prophylaxis
n = 50 (lung, colon, ovarian)
% of Cases
Number of Cases
UFH Q8
42%
21
LMWH 40mg
14%
7
SCD’s
6%
3
Warfarin
0%
0
UFH Q12
20%
10
No prophylaxis
18%
9
Resident Following
18%
9
DVT Sheet Complete
36%
18
Malignancy VTE Prophylaxis
38%
Appropriate
Prophylaxis
Inappropriate
Prophylaxis
62%
2006 vs 2009 Appropriate VTE
Prophylaxis Comparison
Medical
Condition
2006
(n=25)
2009
(n=50)
CHF
82%
86%
Pneumonia
88%
70%
Malignancy
84%
62%
Venous Thromboembolism
Management Data
Patient Population
(n = 80)
Gender
% of Cases
Average Age
Male
45%
60
Female
55%
59
Diagnoses
(n = 80)
Diagnosis
Number of Cases
DVT
28 (35%)
PE
35 (44%)
DVT & PE
17 (21%)
Diagnostic Modalities
Diagnostic Test
% of Cases
Doppler
28 (35%)
CT scan
28 (35%)
Doppler + CT scan
15 (19%)
Doppler + d-dimer
1 (1.3%)
CT scan + d-dimer
3 (4%)
VQ Scan + Doppler
1 (1.3%)
V/Q scan
5 (5%)
Standard Order Sheets
Standard Order Sheet
DVT Prophylaxis
% Complete
39 (49%)
*80 applicable cases
PE Treatment
18 (35%)
*52 applicable cases
• 26% of cases were followed by residents
Hypercoaguable Workup
Hypercoaguable
Workup
Done
Not Done
• 4 cases positive:
– Lupus anticoagulant x 2
– Factor V Leiden
– Factor II Mutation
# of Cases
32 (40%)
48 (60%)
Family History
Family History
Positive for DVT
and/or PE
Negative
Unknown/Not
Addressed
# of Cases
9 (11%)
48 (60%)
23 (29%)
Recent Hospitalization History
• Recent Hospitalization – 21 patients
– 18 of the hospitalized patients had medical
conditions that placed them at high risk for VTE
• Surgery
• Pneumonia
• Ulcerative colitis
• DVT
• PE
VTE Treatment
Treatment
# of Cases
UFH
54 (70%) *77 cases applicable
LMWH
23 (29%) *77 cases applicable
IVC Filter + anti-coag
13 (16%) *77 cases applicable
Thrombolytics
0 (0%)
Anticoagulation
Contraindicated
3 (4%)
* Due to GI Bleeding
• Complications from anticoagulation occurred in 7 cases
– 6 lower GI bleeding
– 1 heparin induced thrombocytopenia
Anticoagulation Management
Anticoagulation Mgnt.
Days
Average Coumadin
Start Date
1.7
Average Day INR
Therapeutic
4.2
Anticoagulation Management (cont)
Overlap Treatment
Therapeutic Discharge
INR w/o Adequate
Overlap Treatment
Therapeutic Discharge
INR + Adequate
Overlap Treatment
# of Cases
12
36
Anticoagulation Management (cont)
Overlap Treatment
# of Cases
Non-therapeutic INR
w/ Overlap Tx on
Discharge
11
Non-therapeutic INR
w/o Overlap Tx on
Discharge
8
Anticoagulation Overlap Therapy
30%
70%
Adequate
Therapy
Inadequate
Therapy
2006 vs 2009 VTE Management
Average
Coumadin Start
Date
Average Day INR
Therapeutic
Inadequate
Overlap Tx
2006
2009
2.1
1.7
5.9
4.2
53%
30%
Measures to Improve VTE Prophylaxis
and Treatment at Sisters Hospital
• Physician and Nursing Education
• Public Education
• Utilize DVT Prophylaxis Form
• Utilize Standardized Admission Forms
• Pharmacy Involvement
• Soarian System Integration