venous thromboembolism prophylaxis and management in the medical patient at sisters of charity...
TRANSCRIPT
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
• Arteriovenous foot pumps
• Sequential compression devices
• Elastic stockings
• Warfarin
• Unfractionated Heparin (UFH)
• 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 doctors are not doing enough to doing enough to
prevent DVT cases.”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 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 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 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 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
$680
$17,512 $18,901
$25,554
$0
$10,000
$20,000
$30,000
Patientwithout DVT
or PE
Patient withDVT
Patient withPE
Patient withDVT and PE
Per
Pat
ien
t M
edic
al C
ost
s
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. 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
86%
14%
AppropriateProphylaxis
InappropriateProphylaxis
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
70%
30%
AppropriateProphylaxis
InappropriateProphylaxis
Malignancy VTE Prophylaxisn = 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
62%
38% AppropriateProphylaxis
InappropriateProphylaxis
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 % Complete
DVT Prophylaxis 39 (49%)*80 applicable cases
PE Treatment 18 (35%)*52 applicable cases
• 26% of cases were followed by residents
Hypercoaguable Workup
Hypercoaguable Workup
# of Cases
Done 32 (40%)
Not Done 48 (60%)
• 4 cases positive:– Lupus anticoagulant x 2– Factor V Leiden– Factor II Mutation
Family History
Family History # of Cases
Positive for DVT and/or PE
9 (11%)
Negative 48 (60%)
Unknown/Not Addressed
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 # of Cases
Therapeutic Discharge INR w/o Adequate Overlap Treatment
12
Therapeutic Discharge INR + Adequate Overlap Treatment
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
70%
30%
AdequateTherapyInadequateTherapy
2006 vs 2009 VTE Management
2006 2009
Average Coumadin Start Date
2.1 1.7
Average Day INR Therapeutic
5.9 4.2
Inadequate Overlap Tx
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
