Background:
Compared with patients in the community, patients acutely hospitalized are at higher risk of developing venous thromboembolism (VTE), contributing to patient morbidity and mortality and healthcare costs. The need for thromboprophylaxis for post-surgical patients is well-known and the importance of thromboprophylaxis for acutely-ill hospitalized medicine patients has been increasingly accepted. We aimed to analyze the adequacy of thromboprophylaxis in patients that developed VTE during admission.
Methods:
Utilizing a dataset extracted from our electronic medical records, we performed a case series analysis of patients found to have new-onset VTE over an 18 month period. Patients were risk stratified using the Padua Prediction Score which discriminates between medical patients at high and low risk of developing VTE. Criteria for appropriate thromboprophylaxis by risk stratification and contraindications to prophylaxis were designed by a multidisciplinary team from both medical and surgical services and reviewed by a senior hematologist with specific expertise in thrombosis. Utilizing these criteria, we assessed adequacy of thromboprophylaxis prior to developing VTE during hospitalization.
Results:
After exclusion of patients admitted for major surgical procedures, we in total reviewed 88 cases with hospital-acquired VTE within the Medicine department. With risk stratification assessment, 67 (76.1%) had a Padua Score ≥ 4 suggesting high risk and warranting thromboprophylaxis.
Of the 88 cases, 28 (31.8%) were deemed to have inadequate thromboprophylaxis according to the defined criteria. In 19 of these cases (67.9% of inappropriate), thromboprophylaxis was not initiated in high-risk patients who did not have contraindications at admission. The other reasons for inadequate treatment include: Not restarting thromboprophylaxis after completion of minor procedures, not restarting thromboprophylaxis after resolution of severe thrombocytopenia, and inappropriate management of Heparin-Induced Thrombocytopenia.
Conclusions:
Despite our understanding of the importance of preventing VTE in the acutely-hospitalized medicine patient, thromboprophylaxis continues to be underutilized in high-risk patients. Unsurprisingly and further supporting the utility of risk assessment models, our case series analysis for new-onset VTE during admission had far more patients stratified as high risk as compared to what we would likely see in a cross-sectional study for all-comers admitted to medical services.
Most physicians empirically assess risk for VTE and administer thromboprophylaxis accordingly, a method which can inappropriately stratify a patient. We aim to address this by implementing a new order set for VTE prophylaxis to include a built-in risk stratification calculator to guide assessment and clearly define contraindications that clinicians must select when foregoing thromboprophylaxis.