From: William A Jenkins, MD, FACEP / Venous Thromboembolism Prophylaxis Team
As I am sure that you are all aware, the American College of Chest Physicians (ACCP) released new guidelines this year regarding the prevention of venous thromboembolism (VTE) and the use of antithrombotic therapy for VTE prevention. These guidelines can be reviewed in their entirety in CHEST for those of you who wish to review the entire guideline.
Excela Health has been working for several years to improve the VTE protection provided to our patients. In conjunction with nursing and as a project in partnership with Highmark and now CMS, Excela has taken great strides to support a nursing risk assessment program for VTE beginning hospital day one providing mechanical compression stockings to nonambulatory patients pending the physician’s assessment of VTE risk and the implementation of pharmacologic VTE prevention where indicated. The use of pre-printed order sets and the use of a comprehensive power plan in Cerner has aided the physicians in following the most evidence based guidelines for VTE prophylaxis for our inpatients.
As the guidelines have recently been modified, this monograph will highlight the newest changes and recommendations and provide examples of changes to the pre-printed order sets and the Cerner power plan.
The clinical recommendations are designed to consider the balance of benefit and harm that result in the decision to provide VTE prophylaxis to our inpatients. The guidelines acknowledge that not all patients require VTE prophylaxis and suggest a risk stratification methodology (The Padua Prediction Risk Score) to determine those patients at highest risk.
The Padua Prediction Risk Score
Risk Factor Score
· Active cancer 3
· Previous VTE 3
· Reduced mobility 3
· Known thrombophilic condition 3
· Recent (≤ 1 month) trauma/surgery 2
· Elderly (≥ 70) 1
· Heart/respiratory failure 1
· AMI/ischemic stroke 1
· Acute infection/Rheumatologic disorder 1
· Obesity (BMI≥30) 1
· Ongoing hormonal therapy 1
Patients are deemed high risk if their Padua Risk Score is ≥ 4 or they are admitted to a critical care unit and considered clinically critically ill. (The guidelines address the critically ill however they are not necessarily part of the formal Padua Scoring System. We have modified our score to assure those in critical care areas automatically fall into the high risk category for efficiency and ease in ordering prophylaxis).
Patients are considered low risk for VTE if their risk stratification score is 3 or less.
For acutely hospitalized patients considered low risk for VTE the guidelines recommend AGAINST the use of either pharmacologic or mechanical VTE prophylaxis. It should be stressed that the patient’s risk level may change throughout the course of their hospitalization and thus risk determination is a dynamic process that should be re-evaluated with each change in patient condition or transition of care. The physician must document “low risk/no prophylaxis indicated” – this is easily accomplished on the order sheet or order set.
As stated above, regardless of risk score, critically ill patients (those in the ICU or deemed critically ill clinically) should receive prophylaxis. Low molecular weight heparin (LMWH) or low dose unfractionated heparin (LDUH) is recommended. For critically ill patients who are bleeding, or at high risk for major bleeding mechanical thromboprophylaxis is recommended until a time when pharmacologic agents can be safely initiated.
For acutely hospitalized patients considered high risk for VTE the guidelines recommend anticoagulant thromboprophylaxis with LMWH, LDUH bid, LDUH tid, or fondaparinux (arixtra). For high risk patients who are bleeding, or at high risk for major bleeding mechanical thromboprophylaxis is recommended until a time when pharmacologic agents can be safely initiated.
Attached you will find a copy of the Excela pre-printed order sheets designed to take you through the risk stratification process for VTE and provide you with the ordering choices for appropriate evidence based VTE prophylaxis. In addition, you will find copies of the screens in Cerner dedicated to VTE prophylaxis. VTE Prophylaxis Power Plan
screen shotsVTE Prophylaxis Order Set