Venous Thromboembolism Prophylaxis and Management in the Medical Patient at Sisters of Charity Hospital

1
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

2
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

3
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

4
Case Presentation

• Why did the patient develop a DVT?

5
Presentation Overview

• VTE Background
• VTE Prophylaxis and Treatment
• Joint Commission VTE Safety Guidelines
• Research Question and Methods

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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

7
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

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VTE Risk Factors

• History of venous thromboembolism
• Malignancy
• Preexisting respiratory disease
• Congestive heart failure
• Oral contraceptives

• Age
• Immobilization
• Surgery within the last three months
• Stroke
• Family history

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VTE Risk Factors

• Additional identified in women
• Obesity
• Heavy Cigarette smoking
• Hypertension
• Patients with Idiopathic PE
• Factor V Leiden mutation
• Increased factor VIII

• Nephrotic syndrome
• Inflammatory bowel disease
• Sepsis
• Hypercoaguable state

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VTE Risk Factors

• The greater the number of risk factors a person
  has, the greater risk of developing a DVT!

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VTE Prophylaxis

• Ambulation
• Arteriovenous foot pumps
• Sequential compression devices
• Elastic stockings

• Warfarin
• Unfractionated Heparin (UFH)
• Low Molecular Weight Heparin (LMWH)
• Fondaparinux
• IVC filter

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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

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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
  2007131507-516.

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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

15
VTE Prophylaxis Background
doctors are not doing enough to prevent DVT
cases.
16
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
  non-surgical patients
• Goldhaber S, Tapson V. A prospective registry of
  5,451 patients with ultrasound-confirmed deep
  vein thrombosis. The American Journal of
  Cardiology 200493259-262

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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

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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
  heparin-induced 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 physicians practice

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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

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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

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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

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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
  dont receive it
• American College of Chest Physicians Guidelines
• Gives anticoagulant prophylaxis in medical
  patients a grade 1A recommendation

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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
MacDougall DA, et. Al. Am J Health-Syst. Pharm.
200663(Suppl 6)s5-15 Cundiff DK. Medscape
General Medicine. 20046(3)5.
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Joint Commission

• The following measures were developed by the
  Joint Commission under the guidance of NQFs
  Prevention and Care of VTE project and are
  currently being pilot tested

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Joint Commission VTE Safety Guidelines

• VTE Risk Assessment/Prophylaxis within 24 hours
  of Hospital Admission
• VTE Risk Assessment/Prophylaxis within 24 hours
  of Transfer to ICU
• Documentation of Inferior Vena Cava Filter
  Indication
• VTE Patients with Overlap Therapy

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Joint Commission VTE Safety Guidelines (cont)

• VTE Patients Receiving Unfractionated Heparin
  with Platelet Count Monitoring
• VTE Patients Receiving Unfractionated Heparin
  Management by Nomogram/Protocol
• VTE Discharge Instructions
• Incidence of Potentially Preventable Hospital
  Acquired VTE

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VTE Treatment in Hospital

• Initiate treatment with full dose LMWH, UFH, or
  fondaparinux for at least 5 days and until the
  INR is gt 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

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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

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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?

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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

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Methods

• Retrospective chart review of patients diagnosed
  with and admitted to the hospital from 1/08 with
• CHF
• Pneumonia
• Known cancer (lung, colon, ovarian)

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Methods (cont)

• Each chart was reviewed for
• Appropriate DVT prophylaxis
• DVT prophylaxis sheet completed
• Standardized admission forms completed if
  applicable

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Methods (cont)

• Retrospective chart review of patients diagnosed
  with VTE from January 2008 present at Sisters
  of Charity Hospital

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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

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Methods (cont)

• Compare 2006 and 2009 VTE Prophylaxis and
  Management Data Comparison

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VTE Prophylaxis Research Data
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CHF VTE Prophylaxis(n 50)
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CHF VTE Prophylaxis
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Pneumonia VTE Prophylaxis(n 50)
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Pneumonia VTE Prophylaxis
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Malignancy VTE Prophylaxisn 50 (lung, colon,
ovarian)
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Malignancy VTE Prophylaxis
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2006 vs 2009 Appropriate VTE Prophylaxis
Comparison
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Venous Thromboembolism Management Data
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Patient Population(n 80)
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Diagnoses (n 80)
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Diagnostic Modalities
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Standard Order Sheets

• 26 of cases were followed by residents

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Hypercoaguable Workup

• 4 cases positive
• Lupus anticoagulant x 2
• Factor V Leiden
• Factor II Mutation

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Family History
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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

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VTE Treatment

• Complications from anticoagulation occurred in 7
  cases
• 6 lower GI bleeding
• 1 heparin induced thrombocytopenia

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Anticoagulation Management
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Anticoagulation Management (cont)
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Anticoagulation Management (cont)
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Anticoagulation Overlap Therapy
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2006 vs 2009 VTE Management
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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

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