An Evidence-Based Algorithm for Determining Venous Thromboembolism Prophylaxis After Degenerative Spinal Surgery.

Venous Thromboembolism in Plastic Surgery: Where Are We Now?

Process Improvement in Prophylaxis for Venous Thromboembolism

Retrospective cohort study. To examine the impact of early (<48 hr) versus late (≥48 hr) initiation of pharmacological venous thromboembolism (VTE) prophylaxis on outcomes and complications among trauma patients undergoing operative fixation of spine fractures. VTE complications are associated with poor outcomes after trauma. Although pharmacological prophylaxis decreases the risk of VTE after trauma, concerns regarding bleeding-related complications among certain patient subgroups persist. At present, there are limited data regarding the safety of early VTE prophylaxis in trauma patients undergoing operative fixation of spine fractures. We performed a 5-year retrospective analysis of our level 1 trauma center registry to identify consecutive patients undergoing operative fixation of spine fractures. Demographics, injury patterns and severity, details of operative procedures, timing of administration of VTE prophylaxis, and outcomes were analyzed. Patients receiving early VTE prophylaxis were compared with patients receiving late VTE prophylaxis. Multivariate analysis was performed to identify independent predictors of VTE. Of 1432 patients with spine fractures, 206 patients (14.4%) underwent operative fixation. Forty-eight (23.3%) received early VTE prophylaxis and 158 (76.7%) received late VTE prophylaxis. No patient developed an epidural hematoma or postoperative bleeding necessitating intervention in either group. Thirteen patients (6.2%) developed VTE, of which 12 occurred in the late VTE prophylaxis group. Age 45 years or more (odds ratio = 5.12, 95% confidence interval = 1.01-25.94, P = 0.048) and traumatic brain injury (odds ratio = 6.94, 95% confidence interval = 1.19-40.35, P = 0.031) were independently associated with an increased risk for VTE. Pharmacological VTE prophylaxis initiated within 48 hours of operative fixation of traumatic spine fractures seems to be safe and is not associated with an increased risk of bleeding or neurological complications. Large, multicenter prospective studies are required to further define the efficacy and safety of an early pharmacological VTE prophylaxis strategy in this at-risk patient population. 3.

To evaluate the prevalence of risk for venous thromboembolism (VTE) and the proportion of at-risk patients who receive appropriate thromboprophylaxis among inpatients in acute hospital care settings in Oman. A related objective was to evaluate the type and time of initiation of VTE prophylaxis. This multicenter, cross-sectional study was conducted in three tertiary hospitals in Oman. The study included acutely ill medical and surgical inpatients admitted from August to September 2022. VTE risk assessment and prophylaxis were assessed based on the 2012 recommendations of the American College of Chest Physicians (ACCP). A total of 384 patients were enrolled, 240 were medical patients and 144 were surgical patients. As per the ACCP criteria, 179 (74.6%) of medical and 92 (63.9%) of surgical patients were at risk for VTE and required prophylaxis. Appropriate prophylaxis was received by 142 (79.3%) at-risk medical and 70 (76.1%) at-risk surgical patients. In cases where pharmacological prophylaxis was contraindicated, mechanical prophylaxis was markedly underused. For medical patients, the median day of initiating VTE prophylaxis was day one of admission. For surgical patients, the median day of initiating VTE prophylaxis was postoperative day one. The majority of hospitalized patients in Oman are at risk of VTE. However, a significant minority of patients do not receive the required pharmacological or mechanical prophylaxis. We recommend the development of a national VTE risk assessment and guiding tool with a facility for monitoring compliance.

INTRODUCTION: Patients hospitalized for traumatic spine injury have an elevated risk for venous thromboembolism (VTE) and thus early initiation of chemical VTE prophylaxis is critical. In the setting of surgical intervention, the risk of post-operative bleeding from early initiation must be weighed against the risk of elevated VTE development from delayed initiation. There is a lack of consensus on ideal timing of chemical VTE prophylaxis initiation in this population. METHODS: Patients who underwent surgery for spinal trauma at our institution were identified. Date of surgery, start date of VTE prophylaxis, complication rates, and other relevant data were collected. Patients who started VTE prophylaxis within 24 hours of surgery were put in the ultra-early group, and those who started after 24 hours in the standard group. Fisher’s exact test was utilized to compare rates of clotting complications and bleeding complications between groups. RESULTS: 261 patients (mean age 50.1, 67.8% male) were included. 163 patients (62%) were in the ultra-early prophylaxis group, compared to 98 (38%) in the standard group. 16 of 261 (6%) patients experienced VTE. Differences in rates of clotting complications in the ultra-early vs standard VTE prophylaxis groups were not statistically significant (early: 7.5%, late 4.1%; p=0.30). 6 of 261 (2%) experienced bleeding complications, 2 of which were GI bleeds and 4 of which were surgical site hematomas. Differences in rates of bleeding complications in the ultra-early vs standard VTE prophylaxis groups were not statistically significant (early: 2.5%, late 2.0%; p&gt;0.99). CONCLUSIONS: There were no significant differences in rates of DVT or bleeding complications between groups. We provide evidence that ultra-early initiation of chemical DVT prophylaxis is safe and should be considered in this population.

Perception of Chemical Venous Thromboprophylaxis for Oncologic Lung Resections among Thoracic Surgeons

Given the vagaries of published guidelines and the lack of high-quality evidence on the method, timing, and dose of venous thromboembolism (VTE) prophylaxis in neurological surgery, little is known about practice patterns regarding VTE prophylaxis in the United States. To estimate the use of VTE prophylaxis in patients who underwent surgery for a cerebral neoplasm and to identify patient, physician, and hospital characteristics associated with prophylaxis. Using the Premier Perspective database, we classified patients undergoing surgery for intracranial neoplasm between 2006 and 2012 on the basis of the type of VTE prophylaxis they received (mechanical, pharmacological, or combination). Generalized estimating equations were used to analyze the effects of pretreatment patient and system variables, including hospital and surgeon volume, on prophylaxis while controlling for hospital clustering. A total of 43 327 patients were identified. Venous thromboembolism prophylaxis was given to 70.2% of patients. Overall, 16 957 (39.2%) had only mechanical prophylaxis, 5628 (13%) received only pharmacological prophylaxis, and 7826 (18.1%) received combination prophylaxis. Patients with high-volume providers (odds ratio, 2.22; 95% confidence interval, 1.33-3.69) were more likely to receive prophylaxis. Nearly one-third of patients who underwent surgery for an intracranial tumor did not receive any VTE prophylaxis. We noted that the rate of overall VTE prophylaxis did not significantly change over the course of the 7years analyzed despite an increasing focus on complication prevention. High-volume surgeons were more likely to provide VTE prophylaxis.

Venous thromboembolism (VTE) is the most preventable cause of morbidity and mortality in US hospitals, and approximately 2.5% of emergency general surgery (EGS) patients will be diagnosed with a VTE event. Emergency general surgery patients are at increased risk of morbidity and mortality because of the nature of acute surgical conditions and the challenges related to prophylaxis. MEDLINE, Embase, and the Cochrane Database of Collected Reviews were searched from January 1, 1990, through December 31, 2015. Nearly all operatively and nonoperatively treated EGS patients have a moderate to high risk of developing a VTE, and individual risk should be assessed at admission. Pharmacologic prophylaxis in the form of unfractionated or low-molecular-weight heparin should be considered unless an absolute contraindication, such as bleeding, exists. Patients should receive the first dose at admission to the hospital, and administration should continue until discharge without missed doses. Certain patient populations, such as those with malignant tumors, may benefit from prolonged VTE prophylaxis after discharge. Mechanical prophylaxis should be considered in all patients, particularly if pharmacologic prophylaxis is contraindicated. Studies that specifically target improved adherence with VTE prophylaxis in EGS patients suggest that efficacy and quality improvement initiatives should be undertaken from a system and institutional perspective. Operatively and nonoperatively treated EGS patients are at a comparatively high risk of VTE. Despite gaps in existing literature with respect to this increasing patient population, successful best practices can be applied. Best practices include assessment of VTE risk, optimal prophylaxis, and physician, nurse, and patient education regarding the use of mechanical and pharmacologic VTE prophylaxis and institutional policies.

HighlightsPublic health relevance—How does this work relate to a public health issue?Venous thromboembolism (VTE) constitutes a significant cause of preventable morbidity and mortality among trauma patients globally.Standardized risk assessment scales are essential tools for identifying high-risk trauma patients who require VTE prophylaxis.Public health significance—Why is this work of significance to public health?This study demonstrates that using specific risk assessment scales can reduce the incidence of deep vein thrombosis and pulmonary embolism in trauma care settings.Preventing hospital-acquired VTE in trauma patients significantly reduces healthcare expenses and long-term complications.Public health implications—What are the key implications or messages for practitioners, policy makers and/or researchers in public health?Practitioners are advised to consistently utilize validated risk assessment scales to inform clinical decision-making concerning VTE prophylaxis within trauma departments.Hospitals and policymakers should require VTE risk stratification protocols as a standard quality indicator for trauma care.Background: Venous thromboembolism (VTE) is associated with high morbidity and mortality. The activation of multiple pathways of venous thrombosis occurs after an injury. A prophylaxis protocol is necessary to prevent early and late venous thrombotic complications. Methods: This study aimed to evaluate the outcomes of venous thromboembolism using the Greenfield risk assessment profile score and its association with bleeding complications. This was a retrospective cohort study conducted on trauma cases who were aged 15 years or older. The study was conducted from January 2020 through December 2022. Patients who were admitted to hospital for less than 24 h or those who died during resuscitation or treatment in an emergency room were excluded from this study. Results: We enrolled 580 cases. Among them, 46.6% were categorized as high-risk for developing venous thromboembolism, and 30.4% of these high-risk patients received pharmaco-mechanical thromboprophylaxis. All VTE cases were high risk according to the Greenfield risk assessment profile, accounting for 3% of the entire group and 1.4% of all enrolled cases. All major bleeding complications occurred with a previously diagnosed large subdural hematoma. Conclusions: Assessing VTE risk was crucial for optimal management of prophylaxis. Proper use of pharmacological prophylaxis had to be balanced against the risk of bleeding complications.

Defects in Processes of Care for Pharmacologic Prophylaxis Are Common Among Neurosurgery Patients Who Develop In-Hospital Postoperative Venous Thromboembolism

See article, page 799

To evaluate venous thromboembolism (VTE) prophylaxis adherence and effectiveness in orthopaedic trauma patients who had vascular or radiographic studies showing deep vein thromboses or pulmonary emboli. Retrospective review. A level I trauma center that independently services a 5-state region. Four hundred seventy-six patients with orthopaedic trauma who underwent operative treatments for orthopaedic injuries and had symptom-driven diagnostic VTE studies. The medical records of patients treated surgically between July 2010 and March 2013 were interrogated using a technical tool that electronically captures thrombotic event data from vascular and radiologic imaging studies by natural language processing. Patients were evaluated for hospital guideline-directed VTE prophylaxis adherence with mechanical or chemical prophylaxis. Patient demographics, associated injuries, mechanism of injury, and symptoms that led to imaging for a VTE were also assessed. Of the 476 orthopaedic patients who met inclusion criteria, 100 (mean age 52.3 median 52, SD 18.3, 70% men) had positive VTE studies. Three hundred seventy-six (age 47.3, SD 17.3, 69% men) had negative VTE studies. Of the 100 patients with VTE, 63 deep vein thromboses, and 49 pulmonary emboli were found. Eight-five percent of all patients met hospital guideline-VTE prophylaxis standards. The study population had better than previously reported VTE prophylaxis adherence, however, patients still developed VTEs. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Venous thromboembolism (VTE) is common after intracerebral hemorrhage (ICH). Guidelines recommend early VTE prophylaxis. To determine characteristics associated with early chemoprophylaxis (CP) after ICH in the Get With The Guidelines-Stroke registry. In this observational cohort study, we identified patients with ICH between January 1, 2009 and September 30, 2013, who (1) were non-ambulatory and/or not comfort care measures by hospital day 2; (2) were not transferred to another acute care facility; and (3) had known VTE prophylaxis status at end of hospital day 2. Categories for VTE prophylaxis were as follows: (1) mechanical non-CP or (2) CP with or without mechanical prophylaxis. Early prophylaxis was defined as occurring by hospital day 2. Using multivariable logistic regression, we assessed patient, hospital, and geographic factors independently associated with early CP use. Among 74 283 patients with ICH from 1358 hospitals, 5929 (7.9%) received early CP, 66 444 (89.4%) received early mechanical/non-CP, and 1910 (2.6%) had no prophylaxis, mechanical or CP, within the first 2 days. There was no increase in early CP use over the study period; 60% of hospitals provided early CP to <9% of patients. In multivariable analysis, female sex, atrial fibrillation, diabetes, coronary, carotid, and peripheral artery disease, prior ischemic stroke or transient ischemic attack, hospital size >500 beds, and geographic region were independently associated with early vs no early CP use. Nationwide, the large majority of ICH patients receive early mechanical VTE prophylaxis only, without CP. Patient comorbidities and hospital characteristics such as geographic location are determinants of higher use of early CP.

Aim Venous thromboembolism (VTE) is a serious global health care safety concern for both patients and staff. Although it has been amply demonstrated that pharmaceutical and mechanical methods of prophylaxis against VTE are effective, their application has been uneven and insufficient. The purpose of this audit was to assess junior physicians working in general surgery, regarding their adherence to local and NICE guidelines regarding the pharmacological VTE prophylaxis practice as well as the mechanical prophylaxis Methodology Pre-intervention audit took place for two weeks. Throughout the course, it covered every adult general surgical emergency inpatient admission at conquest hospital who were deemed indicated for VTE prophylaxis. Each evening while the patients were still in the hospital, data was collected using the prescription charts, nursing and medical notes. The proforma used for data collection detailed the characteristics of VTE risk, the prophylactic medication prescribed for each patient, TED stockings and whether or not this aligned with the NICE clinical guideline (CG) 46,6.8. Post intervention took place for two weeks after teaching of junior doctors and the same as above was carried out, using the new proforma Results Pre-intervention showed that 87% of patients had the proforma filled in and 100% of patients received the appropriate dose of pharmaceutical prophylaxis. However, less than 40% of patients received the appropriate mechanical prophylaxis. Therefore, intervention was made in the form of a new proforma and teaching to junior. Post intervention data is currently being carried out Conclusion Implementation was necessary to ensure that at-risk patients receive appropriate prophylaxis.

Introduction Venous thromboembolism (VTE) prophylaxis is commonly administered to patients across many hospital settings; however, it can be more challenging to address in frailty patients. These patients are more likely to have contraindications to anticoagulation and be ‘delayed discharges’ (medically fit for discharge and at baseline mobility), at which point VTE prophylaxis may not be indicated. Method This quality improvement project was carried out in the acute geriatric ward at St John’s Hospital. With the aim to improve VTE prophylaxis (appropriately prescribed and deprescribed when delayed discharge) in frailty inpatients by December 2024, through education of medical staff and by creating a Trak proforma. Teaching was provided to ward medical staff and a new delayed discharge Trak proforma was created. This prompted a review of VTE prophylaxis deprescribing when patients were medically fit for discharge. A simultaneous QI project created an admissions proforma which prompted a review of VTE prophylaxis prescribing when a patient was first admitted to the ward. Results Before the intervention, only 58% of patients in Ward 8 had VTE prophylaxis correctly prescribed on admission. Many patients (40%) remained on VTE prophylaxis despite being delayed discharges. A staff survey revealed a higher confidence level around prescribing VTE prophylaxis than deprescribing. Only 44% of staff regularly considered stopping VTE prophylaxis once a patient was a delayed discharge. After the intervention, an increased number of patients (74%) had correct VTE prescriptions on Ward 8 admission (28% improvement). Only 16% of delayed discharge patients remained on VTE prophylaxis (60% improvement). Conclusion This project improved rates of VTE prescribing in patients admitted to an acute frailty ward and deprescription rates in patients where VTE prophylaxis was no longer indicated by prompting regular reviews of these prescriptions. This intervention could be utilised in other departments.