Background:
New guidelines by the American College of Physicians (ACP) recommend assessment of the risk of bleeding in medical patients prior to initiation of prophylaxis for venous thromboembolism (VTE). Thus, a routine pharmacoprophylaxis approach for all medical patients without the evaluation of bleeding has been postulated to result in a greater risk of anticoagulation related bleeding. In some patients, this bleeding risk may be more than any potential benefit of VTE risk reduction. Our large tertiary care academic medical center focused on increasing VTE prophylaxis for all medical inpatients by the use of a multilayered VTE prophylaxis quality improvement project implemented over a three year period. The incidence of complications related to anticoagulation such as bleeding was monitored before and after the implementation of this hospital wide prophylaxis strategy.
Methods:
A multi–layered strategy was developed to improve VTE prophylaxis rates for all medical inpatients and consisted of EMR integration of admission order sets, initiation of a 24–h EMR alert to ensure compliance, development of a real time prophylaxis report, and the use of pharmacists in monitoring and ensuring universal prophylaxis. Contraindications to prophylaxis were standardized and defined as upcoming procedure, risk of or active bleeding, hemophilia, coagulopathy, or low platelets. More specific individual patient risk factors for bleeding were not incorporated into the prophylaxis decision. Total VTE rate per 1,000 discharges and complications related to anticoagulation such as bleeding were monitored by the ICD–9 diagnosis code of E934.2. The pre and post intervention phases were September 2008 to March 2010 and April 2010 to August 2011, respectively, and comprised a total of 43,070 patients.
Results:
Over the three year study period, the overall VTE rate decreased from 14.1 to 11.2 per 1,000 discharges. Complications related to anticoagulation such as bleeding were 6.1 and 5.7 pre and post intervention respectively (Figures 1 and 2).
Conclusions:
A universal prophylaxis strategy for medical patients combined with physician use of a standardized list of contraindications to pharmacoprophylaxis did not lead to more complications related to anticoagulation such as bleeding. Future research should focus on the development of a validated tool to assess individual bleeding risk and future guidelines should incorporate more specific bleeding risk assessment measures so they can be weighed relative to the benefit of VTE risk reduction.
