1 PREVENTION OF VENOUS THROMBOEMBOLISM 2005Where are we now? What is the evidence? What is the role of the hospitalist? How to effect change in your hospital?

2 KEY OBJECTIVES To increase awareness of the risk of venous thromboembolism (VTE) especially in the non-surgical patient population To recognize the need for primary prevention in all patients at risk To provide physicians caring for inpatients with evidence-based “Best Practice” standard for targeted VTE prophylaxis

3 AGENCY FOR HEALTHCARE RESEARCH & QUALITY: AREAS FOR SAFETY IMPROVEMENTRanked in order of need for widespread implementation for hospitalized patients: Venous thromboembolic prophylaxis in patients at risk • Perioperative use of -blockers in appropriate patients • Use of maximum sterile barriers while placing central intravenous catheters • Appropriate use of antibiotic prophylaxis in surgical patients • Verification of patient understanding of informed consent Shojania KG et al. Making healthcare safer: a critical analysis of patient safety practices. AHRQ publication 01-E058, 2001.

4 NATIONAL QUALITY FOUNDATION“ Deep venous thrombosis (DVT) is a very important but very under-recognized clinical condition, and the lack of standardized performance measures to gauge the quality of care for DVT and its complications is a serious short-coming.” -Kenneth W. Kizer, MD, NQF President

5 JCAHO & NATIONAL QUALITY FOUNDATIONJoint Initiative: DVT Prevention and Care Project, September, 2004 • To develop and standardize performance measures for the prevention, as well as the care, of deep vein thrombosis (DVT). • To develop organizational policies and procedures, care practices, and appropriate improvement interventions.

6 DVT SAFETY ZONE QUALITY IMPROVEMENT PROGRAMA national awareness initiative to: Increase the level of awareness about VTE with all providers Use a multi-faceted, multi-specialty program to decrease VTE incidence within every hospital

7 DVT SAFETY ZONE QUALITY IMPROVEMENT PROGRAMService provided by Aventis to customers that may provide the following value-added benefits: • Improved patient outcomes (less VTE) • Improved public image (pharmaceutical community outreach) • Assistance in JCAHO certification • Cost reduction (less resource utilization) • Reduced legal risk re: VTE prevention

8 VTE IS HIGHLY PREVALENTAn estimated 260,000 cases of clinically recognized VTE occur each year in patients hospitalized for acute care1 Pulmonary embolism (PE) is associated with high mortality rates2 and is considered one of the most common preventable cases of hospital death3 DVT is associated with a high risk of recurrence and postthrombotic syndrome (PTS)4 1-year mortality rate after PE was 39%, after DVT 21% in a study of elderly patients5 Effective thrombopropylaxis is underutilized6 1 Anderson FA et al. Arch Intern Med. 1991; 151: 2 Goldhaber SZ et al. Lancet; 1999: 3 Ciagett GP et al. Chest. 1995:108(suppl):312S-314S. 4 Prandoni P et al. Haemetologica. 1997; 82: 5 Kniffin WD Jr et al. Arch Intern Med. 1994;154(8):861-6. 6 Geerts WH et al. Chest. 1001:119(suppl):132S-175S.

9 ICOPER: CUMULATIVE MORALITY AFTER DIAGNOSIS5 10 15 20 25 17.5% Mortality (%) 7 14 30 60 90 Days From Diagnosis Lancet. 1999;353:

10 ECONOMIC BURDEN OF VTE PE DVT MI Stroke Inpatient Costs $12,148 $7001$12,680 $11,514 0 $2500 $5000 $ $10,000 $12, ,000 Inpatient Costs MI = Myocardial Infarction AHRQ – Statistics from the HCUP-3 nationwide inpatient sample for 1994: DRG. Available at Accessed April 7, 2004.

11 Post-Phlebitic Syndrome Pulmonary HypertensionECONOMIC BURDEN OF VTE DVT 2 Million PE 600,000 Post-Phlebitic Syndrome 800,000 Silent PE 1 Million 10% Pulmonary Hypertension 30,000 Death 60,000 VTE: $1.5 Billion/year Lancet 1999;353:

13 ECONOMIC BURDEN OF VTE Large number of patientsHigh costs of management Additional long-term healthcare costs of DVT – estimated 75% initial cost 1. Bick, R.L. Clin Appl Thromb Hemost. 1999;5:2-9 2. Bergqvist, D. et al. Ann Intern Med 1997;126:

14 CASE #1: FEAR OF BLEEDING33 year old female –No PMH, except mild obesity • N/V/D • diffuse abdominal pain • left-sided chest pain • BUN 51 mg/dL, Cr 12 mg/dL

15 CASE #1: FEAR OF BLEEDINGHospital Course • Hospital Day#9: patient collapses, code blue called Bedside Echocardiogram: • severely dilated/hypokinetic RV • under filled LV Pathology at Autopsy • large, acute bilateral pulmonary emboli • no leg/pelvic DVT

16 FAILURE TO PROPHYLAX: DVT FREE Study183 Sites: 5,451 patients • 3,894 (71%) did not receive prophylaxis • Of the 2,726 diagnosed with DVT as inpatients, 58% had not received prophylaxis. • More than twice as many medical patients failed to receive prophylaxis as surgical patients. Goldhaber, S. – Amer J of Cardiol 93:259 (January 2004)

17 FAILURE TO PROPHYLAX: DVT FREE StudyIn DVT Free… 6% received TID minidose heparin versus 94% who received BID SQ heparin No large randomized clinical trial supports the use of heparin 5,000 units SC q12h in medical inpatients. No placebo-controlled trials establish UFH as the standard of care. Only a meta-analysis suggested a 58% reduction in PE, but the main contributing trial was flawed. Mismetti, P. Thromb Haemost. 2000;83:14-19

18 VTE PROPHYLAXIS Failure to prophylax hospitalized medical patients can be lethal Omitting prophylaxis is a much greater problem in medical than in surgical patients When prophylaxed, medical patients often receive inadequate prophylaxis BID SQ heparin, graduated compression stockings (GCS), sequential compression devices (SCD) are not evidence-based in medical patients

19 INCIDENCE OF DVT Correlation with the number of risk factors100% 100% 80% Positive result (%) 60% 50% 36% 40% 24% 20% 11% 0% 1 2 3 >3 Number of risk factors Wheeler, et al. Arch Surg 1981.

20 VTE IN MEDICAL PATIENTSFrequency of DVT in Absence of Prophylaxis General Medical % Cade 1982, Belch et al , Samama 1999 Stroke % Nicolaides et al. 1997 MI % Nicolaides et al. 1997 SC Injury % Nicolaides et al. 1997 CHF % Anderson et al. 1950 MICU % Cade ‘82, Dekker et al. ‘91, Hirsh et al. '95 Cancer % Levine 1998, Goodnough 1984 Compared with surgical populations, far fewer studies have reported on the frequency of VTED in medical patients. However, those figures that are available suggest a moderate risk of deep vein thrombosis (DVT) in general medical patients in the absence of prophylaxis [8,9] according to the risk categories (low, moderate, high) defined by Salzman and Hirsh for surgical patients [10], with much higher rates in specific groups, as seen on this slide [7-9,11-14]. A recent study reported that up to one in 20 hospitalized medical patients with multiple problems and severe immobility may suffer fatal PE [15]. It should be noted, however, that the figures for VTED rates following myocardial infarction (MI) shown on the slide are based on studies conducted in the 1970s; with modern management practices with extensive use of thrombolytics, unfractionated heparin (UFH), low-molecular-weight heparin (LMWH) and antiplatelet agents, the incidence may now be lower. 2

21 PATIENT-RELATED RISK FACTORS AS IMPORTANT AS SPECIFIC ADMITTING DIAGNOSISAge >70 years (any age, increasing after 40) Immobility, stroke or paralysis Malignancy and its treatment Pregnancy, oral contraceptives PMH VTE, varicose veins Inherited and acquired molecular risk factors Metabolic abnormalities, IBD, nephrotic syndrome

22 SPECIFIC MEDICAL CONDITIONS ALONE NOT ACCURATE PREDICTORS OF RISKSpecific disease not only factor affecting risk Overlap of moderate risk and high risk for the same condition depending on severity of disease Multiple risk factors affecting total risk in medical patients

23 ADDITIONAL VTE RISK: MEDICAL INTERVENTIONChemotherapy Invasive medical technologies Indwelling foley Total eligible population much greater than simply high-risk subgroups

24 STUDIES IN VTE PREVENTIONAuthor Population (N) Treatments Detection DVT Rate P value Halkin (1982) General Medical (1358) Placebo vs UFH 5000 U BID Clinical Dx 10.9% vs 7.8% NS Caulin (1989) General Medical (2474) Nadroparin 7500 U QD 10.3% vs 10.1% Gardlund (1996) Infectious Disease (11,693) 5.6% vs 5.3% These studies should be reviewed with respect to their large patient populations, the population studied, and the doses used. The treatment modalities were unfractionated heparin 5000 units twice daily (for Halkin and Gardlund) or the LMWH nadroparin 7500 units once daily (for Caulin), compared against placebo. The detection endpoint was based on clinical diagnosis. In these studies, there was no difference in DVT rates with use of heparin or nadroparin compared with placebo in these medical populations. Also, it may be significant to highlight the fact that the patient populations in these older studies likely included patients who were less medically ill than the population of hospitalized patients today.

25 MEDICAL PROPHYLAXIS: +/- UFHUFH tid vs Placebo 100 patients with CHF and/or chest infection randomized to UFH 5,000 U SC q8h until mobile or no prophylaxis DVT diagnostics: 125I – fibrinogen scans every 2 days for 14 days or until discharge Findings: Patients diagnosed with DVT: 4% (UFH) vs. 26% (control) (p < 0.01) Two control patients with (+) scans readmitted with PE 20% of UFH patients excessive bruising at injection site Belch Scott Med J 1981;26:

26 VTE PREVENTION IN HIGH RISK MEDICAL PATIENTSUFH 5000 units SQ tid is more effective than no treatment The evidence is less convincing that UFH 5000 units bid is more effective than placebo Study limitations: • Small study populations • Variations in endpoint measurement • Open label, non-randomized

27 General Medical ConditionsPREVENTION OF VTE General Medical Conditions Author Population (n) Treatments Detection Event rates (%) P value PRINCE 665 Enox 40 mg qd LDUFH 5000 U tid D-Dimer Venography 8.4 v 10.4 NS [Equiv] Stroke Study Harenberg 212 630 Enox 40 mg qd LDUFH 5000 U tid 19.7 v 34.7 15.6 v 22.1 0.044 0.04 Samama 1999 (MEDENOX) 1,102 Enox 20 mg qd Placebo 15.0 5.5 14.9 NS vs p <0.001 vs p Enoxaparin Studies

28 MEDENOX DESIGN A placebo-controlled multi-center, randomized, double-blind trial to prevent VTE in acutely ill hospitalized medical patients Enoxaparin 20 mg or 40 mg QD versus placebo for 6 to 14 days (three parallel groups) 1102 hospitalized patients with an acute medical disorders Samama MM, et al. NEJM. 1999;341:

29 VTE INCIDENCE AT DAY 14 ~1 in 6 medical patients develop VTE with “nothing” P=0.0002 16 Placebo 14.9 15.0 14 Enox 20 mg 12 - 63% Enox 40 mg 10 (%) P=0.0370 Duration of tx: days Median: days 8 6 5.5 - 65% 4 4.9 4.5 About two-thirds of the patients in MEDENOX had two or more risk factors. Of the 866 evaluable patients, 92 developed VTE within the first 14 days (the primary endpoint). Within the first 14 days, VTE developed in 16 patients (5.5%) receiving enoxaparin 40mg, 43 patients (15.0%) of those receiving enoxaparin 20mg, and in 43 patients (14.9%) receiving placebo. Thus, there was nearly a 10% absolute decrease in the incidence of VTE with enoxaparin 40 mg daily. This means that one VTE was prevented for every 10 patients treated. Within the first 14 days, the relative risk of patients receiving enoxaparin 40mg who developed disease was 0.37 (a 63% relative risk reduction), with a 97.6% confidence interval of 0.22 to 0.63 (P = < 0.001). NS 2 1.7 All VTE Proximal DVT PE 59% reduction at day 110 (p< 0.001) in all VTE No increase in major bleeding in treatment group. Mortality reduction with 40mg 3.3% vs. placebo 4.4% (p = 0.31) N Engl J Med 1999;341:793.

30 MEDENOX CONCLUSIONS Acutely ill medical patients are at significant risk of VTE (15% total VTE, 5% proximal DVT) Enoxaparin 40 mg once-daily given subcutaneously for 6 to 14 days was effective in reducing the risk of VTE by 63% Benefit was maintained at 3 month follow-up This result was achieved with no increase in adverse events, hemorrhage or  platelets Samama MM, et al. NEJM 1999;341:

31 MEDENOX ECONOMIC ANALYSISA pharmacoeconomic model evaluated VTE prophylaxis based on MEDENOX criteria in two simulated 3,000 patient cohorts. Enoxaparin accounted for 1.2 to 2.4% of the admission cost $23 ( $28) to $99 ( $122) to complete prophylaxis as an outpatient Cost effectiveness: $1,249 - $3,088 per VTE avoided Format Am J Manag Care 2002;8(12):

32 PREVENT DESIGN (ANOTHER LMWH)Patients with one or more of the following: CHF (NYHA III, IV) Acute respiratory failure Acute severe systemic disease plus 1 risk factor RCT Design: Anticipated hospitalization >4 days Dalteparin 5000IU SC q day versus placebo 12 to 14 days treatment Goldhaber, S et al PREVENT Medical Thromboprophylaxis Study Group, Circulation 2004; 110:

33 PRIMARY EFFICACY ENDPOINTDalteparin N=1518 Placebo N=1473 Difference in Incidence (%) Risk Ratio 42 2.77% 73 4.96% -2.19 0.55 -3.57 to -0.81 0.38 to 0.80 95% CI Analysis of the primary efficacy endpoint at Day 21 showed that compared with placebo, prophylactic treatment with dalteparin was associated with a clinically meaningful reduction in risk ratio of (45% decrease in the risk) of experiencing a symptomatic DVT (proximal or distal), nonsymptomatic proximal DVT and/or near fatal and fatal PE and sudden death. The incidence of events was 2.77%. Although the study was designed with an alpha of 0.001, the results provide strong statistical evidence of treatment effect (and reliable evidence that the null hypothesis can be rejected). Low probability that this is a chance finding. P=0.0015* *Cochran-Mantel-Haenszel Test.

34 EFFICACY OUTCOMES MEDENOX 1, PREVENT 2, ARTEMIS 3Placebo Enoxaparin 20 mg qd Enoxaparin 40 mg qd P value No. patients 288 287 291 VTE 43 (14.9%) 43 (15.0%) 16 (5.5%) 0.0002* PREVENT Dalteparin 0.0015 1473 1518 73 (4.96%) 42 (2.77%) Proximal DVT 60 (4.07%) 29 (1.91%) --- ARTEMIS Fondaparinux ? 10.5% 5.6% 0.029 Samama MM, et al. NEJM 1999;341: Leizorovicz A, et al. J Thromb Haem 2003; 1 Supplement 1 July: abstract OC396. ISTH July 2003. Cohen AT, et al. J Thromb Haem 2003; 1 Supplement 1 July: abstract P2046. ISTH July 2003.

35 BLEEDING RISK: LMWH VERSUS UFHProphylaxis Trials Meta-Analysis Major Bleeding: LMWH UFH p value 10/ / (0.49%) (1.2%) Relative Risk = 0.48 (LMWH superior) With any anticoagulant including heparins being administered we are appropriately concerned with bleeding and HIT. (52% decrease in major bleeding with LMWH) Mismetti. Thrombosis Haemostasis 2000 Jan;83(1):14-9.

36 INCIDENCE OF THROMBOCYTOPENIAUFH 3.4% LMWH 0.4% Warkentin et al

37 EVIDENCE: MEDICAL PROPHYLAXISLMWH vs LDUH tid Moderate Risk Enox = LDUH PRIME (n = 959, equivalence) Enox = LDUH PRINCE (n = 665, equivalence) Enox > LDUH Harenberg et al. (n = 877, superiority) Enox > LDUH Hillbom et al. (n = 212, superiority) High Risk Dalteparin? Fondaparinux ? Bleeding profile across trials more favorable for enoxaparin vs LDUH Ann Hematology 1998;76(suppl I):A Haemostasis 1996;26(suppl2):49. Blood 1999;94(suppl 1): Blood 1999;94(suppl 1):798.

38 CONCLUSIONS • VTE is a major health problem • VTE is preventable• Guidelines for prevention currently exist • Evidence differs between LMWHs and between LMWHs and UFH in VTE prophylaxis • There is a gap between existence of guidelines and implementation in clinical practice • Medical societies / organizations should fill the educational gap

39 COST CONSIDERATIONS • Failed prophylaxis is costly.• Cost calculations must consider Rx of DVT, PE, and H.I.T. • RN time costs should be calculated for multiple daily injections and reapplication of GCS, SCDs. • Patient centered care for the 21st century includes a consideration of patient satisfaction.

40 CASE #2: NOT ON THE RADAR SCREEN76 year old man,  fatigue during daily 40 lap swim and daily 3 mile walk: Testing: Left main + 3-vessel obstructive CAD (cath) Treatment: Uncomplicated 3-vessel CABG 73 minute aortic cross clamp time 80 minute cardiopulmonary bypass time

41 CASE #2: NOT ON THE RADAR SCREENTertiary Hospital Course Hospital Day 1: out of ICU Hospital Day 5: ambulatory 100 feet Hospital Day 6: discharged home on ASA, HCTZ, Metoprolol, Atorvastatin Post-Op Day #30: Local Community Hospital fatigue for prior 5 days 1 day severe shortness of breath

42 RISK STRATIFICATION IN SURGERYLow • Minor surgery; <40ys; no additional risk factors Moderate • Minor surgery with additional risk factors; non-major surgery in 40-60yrs with no additional risk factors; major surgery in <40yrs with no additional risk factors High • Non-major surgery in pts > 60yrs or with additional risk factors; major surgery in pts >40 yrs or with additional risk factors Highest • Major surgery in pts >40 yrsplus prior VTE, CA, or molecular hypercoagulable state; hip or knee arthroplasty;p hip fracture surgery; major trauma; SCI Geerts, WH et al. Chest 2001; 119:132S-175S.

43 LEVELS OF RISK IN SURGERYRisk Calf Proximal Clinical Fatal DVT, % DVT, % PE, % PE, % __________________________________________ Low Moderate High Highest Geerts, WH et al. Chest 2001; 119:132S-175S.

44 7th ACCP RECOMMENDATIONSGeneral Surgery 6th: • In selected very-high-risk general surgery patients, we recommend that clinicians consider postdischarge LMWH or perioperative warfarin (INR 2.0 to 3.0) (grade 2C) General Surgery 7th: • In selected high-risk general surgery patients, including those who have undergone major cancer surgery, we suggest post-hospital discharge prophylaxis with LMWH (grade 2A) Category: Mechanism of Action and Pharmacology of Anticoagulants Key Words: Comparison to UFH Chemistry Mechanism of Action Orthopedic Prophylaxis

45 Antithrombotic Therapy for Venous Thromboembolic DiseaseACCP Conference on Antithrombotic and Thrombolytic Therapy Guidelines Other Prophylaxis Issues for Major Orthopedic Surgery • We recommend that patients undergoing THR or HFS be given extended prophylaxis for up to 28 to 35 days after surgery (Grade 1A). The recommended options for THR include LMWH (Grade 1A), a VKA (Grade 1A), or fondaparinux (Grade 1C+). • We recommend against the routine use of DUS screening at the time of hospital discharge in asymptomatic patients following major orthopedic surgery (Grade 1A) Other Prophylaxis Issues for Major Orthopedic Surgery • Extended out-of-hospital LMWH prophylaxis (beyond 7 to 10 days after surgery) may reduce the incidence of clinically important thromboembolic events, and we recommend this approach at least for high-risk patients (grade 2A because of uncertainty regarding cost-effectiveness) • We do not recommend routine duplex ultrasonography screening at the time of hospital discharge or during outpatient follow- up in asymptomatic THR or TKR patients (grade 1A) Category: Mechanism of Action and Pharmacology of Anticoagulants Key Words: Comparison to UFH Chemistry Mechanism of Action Orthopedic Prophylaxis

46 RISK OF DVT PERSISTS AFTER HOSPITALIZATIONTesting (Case #2) EKG: NSR 79, NSST abnormalities D-dimer >8,000 ng/ml Contrast enhanced spiral CT: large bilateral central PE, right leg DVT Treatment Transfer to tertiary hospital Enoxaparin as a bridge to therapeutic warfarin

47 CHALLENGES PREDICTION IN DETECTION, DIAGNOSIS OF PEPredicting Who Will Have a PE is Difficult Case #1: <38 yrs, minor procedure, no identifiable risk factors Case #2: low risk of VTE based on only mild HBP and excellent physical shape Lifelong, genetic pre-determinants for thrombosis cannot be measured routinely

48 CHALLENGES PREDICTION IN DETECTION, DIAGNOSIS OF PEDiagnosis may not be suspected with vague symptoms Case #2: symptoms could have been ascribed to pericarditis, costochondritis, anxiety in setting of normal HR, BP, EKG Silent, Fatal Disease Unsuspected in 70-80%, diagnosed at autopsy

49 CHALLENGES PREDICTION IN DETECTION, DIAGNOSIS OF PELimitations of testing for PE D-dimer low PPV for PE, especially in post-op patient and sick medical patients Low sensitivity of US lower extremities in asymptomatic patients Multi-detector-row spiral CT scanners not infallible Human factor in interpretation Technical limitations (size, bolus of dye) Timing relative to onset of symptoms Concerns about renal failure in patients at risk

50 CHALLENGES PREDICTION IN DETECTION, DIAGNOSIS OF PEUniversal measures to prevent postoperative VTE are of paramount importance: • Case #1: symptomatic VTE, can result in fatal PE within 2 hours of onset • Case #2: PE the 5th most common cause of readmission post CABG • Estimated lives saved if effective prophylaxis used = 80,000 patients per year

51 VTE OFTEN DETECTED TOO LATE70% 30% At least 70% of fatal PE detected post-mortem was not suspected or diagnosed1,2 At autopsy, approximately 63% of DVT cases were clinically undiagnosed2 One possible interpretation is that we could assess our patients for the development of VTE and then treat the patient when a DVT or PE occurs. However, the problem with such an approach is that VTE diagnosis may be difficult and often goes undetected until it is too late. At least 70% of the time, a fatal PE is not detected until post-mortem. Studies have also shown that at autopsy, approximately 63% of DVT cases were clinically undiagnosed. The 2001 ACCP Consensus Conference publication states that it is inappropriate to wait for the symptoms and then rely on the diagnosis and treatment of established VTE. So what available evidence do we have to clue us into, or point to, the types of patients who are at risk for VTE that enter our hospitals? 1. Stein PD, et al. Chest 1995;110: 2. Sandler DA, et al. J R Soc Med 1989;82:

52 QUESTIONS FOR HOSPITALISTSIs the hospitalized medical patient on the “radar screen” for potential development of DVT/PE? Why are hospital protocols for prophylaxis inadequately implemented? What barriers must we overcome? When should BID SQ heparin or SCD be utilized, in the absence of convincing clinical trials? What is the role of “combo prophylaxis”?

53 VTE PROPHYLAXIS Adequate, evidence-based VTE prophylaxis is still underutilized Predicting who will have a PE is difficult Even low VTE risk procedures carry some risk Universal appropriate preventative measures should be undertaken.

54 VTE PROPHYLAXIS Contraindications to pharmacologic prophylaxis does not mean “No Prophylaxis” SCDs studies looked at use 23 hours out of 24: are your patients wearing them that much? Optional IVC Filters Early Ambulation Do not be reassured by “inadequate prophylaxis” • UFH bid may be placebo dosing in medical patients • ASA does not provide protection Factor in patient satsifaction

55 THE ROLE OF THE HOSPITALIST: SPREAD THE WORDThe imperative to direct therapy against predictable complications of serious illness: • All hospitalized patients, both medical and surgical, should be assessed for VTE risk • In general, “sick, old, or surgery” benefit • VTE prophylaxis is cost effective

56 THE ROLE OF THE HOSPITALIST: SPREAD THE WORDCritically review prophylaxis performance Provide hospital-specific data to clinicians Identify and lower barriers Develop automated reminder systems Devise strategies to bridge the gap between knowledge and practice Understand effective implementation and improvement steps for an organized, continuous VTE QI effort

57 THE ROLE OF THE HOSPITALIST: SPREAD THE WORDYour hospitalist service may be the engine that drives quality improvement in your hospital.

58 ELIMINATE PREVENTABLE DVT AND PE IN THE HOSPITALIMPLEMENT A VTE PROPHYLAXIS PROTOCOL… Download and use the “QI Workbook: VTE” from the VTE Resource Room. Adapt a VTE risk assessment algorithm to meet your local needs.

59 ALGORITHM FOR VTE PROPHYLAXIS DVT Prophylaxis Consensus Panel Guidelines and Recommendations Goldhaber SZ, Tapson V, Elkayam U, Bosker G, Comp PC, Fanikos J, Haire WD, Heit J, Huddleston J, Jaffer A, Kessler C, Lavender RC, Merli GJ, Michota F, Spyropoulos AC, Wheeler A, Yusen RD How do we do this? Let’s start with an algorithm – one that was developed by the DVT Prophylaxis Consensus Panel Committee. Starting from the top, all patients should be screened and considered for VTE prophylaxis. A risk factor assessment is performed to determine if the patient has restricted mobility and at least one of the VTE risk factors again. I will show the risk factors in a minute. If the patient meets these criteria of restricted mobility and at least one other risk factor, then pharmacologic prophylaxis is indicated. We should also note, that in the event the patient does not meet the criteria for pharmacologic prophylaxis upon admission or initial screening, VTE risk factors may develop during hospitalization – which suggests the risk factor assessment process should be continuous or repeated periodically. See the lecture notes associated with this slide.

60 ALGORITHM FOR VTE PROPHYLAXIS DVT Prophylaxis Consensus Panel Guidelines and RecommendationsIf pharmacologic prophylaxis is indicated, we still must ask ourselves if the patient meets any criteria to exclude him or her from pharmacologic prophylaxis. I will come back to these exclusion criteria in a minute. If, however, the patient receives pharmacologic prophylaxis, two specific approaches are presented. First, enoxaparin 40 mg subcutaneously once a day. Or, initiate unfractionated heparin 5000 IU subcutaneously every 8 hours. Note that clinical trials support the use of pharmacologic prophylaxis for 7 to 12 days, although a shorter or longer duration of prophylaxis may be appropriate based on clinical factors or length of hospitalization. For enoxaparin, the usual duration is 6 to 11 days. Up to 14 days has been tolerated in the controlled clinical trial in medical patients with restricted mobility. See the lecture notes associated with this slide.

61 ALGORITHM FOR VTE PROPHYLAXIS DVT Prophylaxis Consensus Panel Guidelines and RecommendationsAgain, these are the risk factors associated with this particular algorithm. They are presented in the table on the left. Starting with age >40 years, presence in the intensive care unit, prior history of VTE, obesity, ischemic stroke, heart failure, chronic lung disease, respiratory failure, pneumonia and so on. The table on the right side contains possible exclusion criteria for pharmacologic VTE prophylaxis. Some of these criteria include active bleeding, hypersensitivity to UFH and LMWH, and uncontrolled hypertension. See the lecture notes associated with this slide.

62 SHM VTE RESOURCE ROOM Topic-oriented resource designed to:introduce QI theory present the evidence most pertinent to VTE prophylaxis support hospitalist efforts to educate and enhance awareness share experiences with VTE-specific QI efforts offer practical, specific guidance to any hospialist wanting to lead a VTE QI initiative at the home institution A resource to lead hospital quality and improve inpatient outcomes Produced through coordination across SHM committees Look for success stories in the new Journal of Hospital Medicine submit your own to: