Helping Canadian Hospitals Meet Accreditation

Requirements For VTE Prophylaxis

Deep vein thrombosis (DVT) forms in a vein of the leg.

• Characterized by pain, swelling or tenderness of the leg, sometimes with redness and warmth

Deep Vein Thrombosis

Pulmonary Embolism

Pulmonary embolism (PE) occurs when the blood clot breaks loose and travels to the lungs

• Characterized by shortness of breath, sharp rib/chest pain and occasionally by hemoptysis, light-headedness, or collapse

Symptoms and Signs of DVT• Leg pain (90%)• Tenderness (85%)• Ankle edema (76%)• Calf swelling (42%)• Dilated veins (33%)• Dusky discoloration

(30%)• Warmth• Redness

DVT cannot be reliably diagnosed on the basis of history and physical exam, even in high-risk patients.

Symptomatic DVT

Most hospitalized patients with DVT

will have NO SYMPTOMS or SIGNS!

Risk of VTE in Hospitalized Patients

Geerts WT, et al. Chest 2008;358:381S-453S.

Patient Group DVT Prevalence (%)

Medical Patients 10-20

General Surgery 15-40

Major Gynecologic Surgery 15-40

Major Urologic Surgery 15-40

Neurosurgery 15-40

Stroke 20-50

Hip and Knee Arthroplasty, Hip Fracture Surgery

40-60

Major Trauma 40-80

Spinal Cord Injury 60-80

Critical Care Patients 10-80

Pulmonary Embolism

Hospital Risk•Accounts for 10% of hospital deaths

•In the UK, PE following DVT causes between 25,000 and 32,000 deaths each year1

International, cross-sectional audit of 35,000 inpatients at risk for VTE found:2

•only 59% of surgical patients and 40% of medical patients received recommended prophylaxis.

1. UK House of Commons Health Committee. HC 99. Published on 8 March 2005.2. Cohen AT, et al. Lancet 2008;371:387-394.

Characterization of VTE events

In the Worcester County, Mass VTE Study•60-70% of VTE events were considered to be provoked by:

• Recent hospitalization (within 3 months)• Surgery• Trauma/fracture• Pregnancy

1. Spencer FA, et al. Arch Intern Med 2007;167:1471-5.2. Spencer FA, et al. J Thromb Thrombolysis 2009;28:401-9.

Risk for VTE increases with the

number of risk factors and

persists after hospital discharge.

Marco’s Story

Adapted from: Greer IA. Bailliere’s Clin Obstet Gynaecol 1997;11:403-30.

The risk of DVT and PE is increased by several factors, including:Factors intrinsic to the

patientFactors related to

underlying disease or medical condition

Factors introduced by medical or surgical

treatment

• Age• Obesity• Immobility• History of thrombosis• Thrombophilia

• Varicose veins• Venous insufficiency• Pregnancy• Trauma• Heart failure/MI• Malignancy

• Concomitant medication• Chemotherapy• Orthopaedic surgery• Major surgery• Caesarean section

1. VTE is common in hospital patients

2. VTE is fatal (acutely and long-term)

3. VTE is preventable (safely and inexpensively)

4. Preventing VTE is the standard of care for almost all hospital patients in 2011

Slide courtesy of Dr. William Geerts.

Rationale for Thromboprophylaxis

Adverse Consequences of VTE

$Slide courtesy of Dr. William Geerts.

Key steps to ensure compliance with ROP:

1.Development of written policy/guideline

2.Identifies clients at risk & provides VTE prophylaxis

3.Establishes measures of success, uses information to make improvements

4.Provides information to health professionals (on risks & prevention measures)

1. Hospital commitment; committee, leadership2. Follow the ACCP guidelines3. Written hospital policy on prophylaxis4. Keep it simple and standardize it 5. Use order sets, computer order entry6. Make prophylaxis decision mandatory7. Involve everyone – MD, RN, pharm, patients8. Audit and feedback to improve best practices

8 steps:

Slide courtesy of Dr. William Geerts.

Local Strategies to Improve Thromboprophylaxis Success

Every in-patient w/o contraindication

should be onVTE prophylaxis

Audrey’s StoryFollowing a one week wait for surgery and the successful removal of a benign tumour – Audrey developed a PE.

We are scared and worried about our surgery or primary reason for being in the hospital as it is. We rely on you to make us aware of any possible complications. For me, the blood clot was far scarier and worse than my brain tumour and operation.

This experience with the blood clot has impacted my life. It was the scariest and worst experience I have ever had and it has left me fearful and anxious.

“My plea to healthcare professionals: make sure you get people’s attention, and make sure they fully understand their risks and what can be done to prevent a blood clot.”

• Written hospital policy on VTE prophylaxis

• Opt-out policy for all medical and surgical in-hospital patients

• VTE prophylaxis embedded in hospital order sets

Policy ensures prophylaxis is considered resulting in lower rates of VTE in hospital setting

Hospital Commitment for VTE Prophylaxis should include:

• Simplicity = single choice

• LMWH advantages over UFH:• once a day administration• lower rates of heparin induced

thrombocytopenia• availability in prefilled syringes

Written hospital policy on prophylaxis - Simplicity

LMWH: low molecular weight heparin; UFH: unfractionated heparin

• Due to differences in LMWH molecule size and charge, longer chained and more charged LMWHs like tinzaparin do not appear to require dose adjustments in patients with:• impaired renal function1

• renal failure2,3

• on haemodialysis2,3

• Dose reduction may be necessary with shorter chain LMWHs (i.e. enoxaparin)

Use of LMWHs in Renal Impairment

1. Mahé O, et al.Thromb Haemost 2007;97:581-6.2. PROTECT Investigators. N Engl J Med 2011;364:1305-14. 3. Nutescu EA, et al. Ann Pharmacother 2009;43:1064-83.

1. Hospital commitment, committee, continued leadership

2. Written hospital policy on prophylaxis

3. Keep policy simple and standardize it

4. Use embedded order sets &/or computer order entry

5. Make prophylaxis decision mandatory

(i.e. opt-out policy)

6. Involve everyone – MD, RN, pharm, patients

7. Audit and feedback essential to measure success and identify problems areas

Implementation

Slide courtesy of Dr. William Geerts.

96%

Success with Policy and Embedding Appropriate Prophylaxis* (use in General IM Patients)

9%

2003 2007 2008 2009

21%

100%

75%

50%

25%

0

60%

*based on direct chart audit

Quality improvement in action!

Slide courtesy of Dr. William Geerts.

Vigilance is Key:Appropriate Prophylaxis* Use in General IM Patients

9%

2003 2007 2008 2009 2010

21%

100%

75%

50%

25%

0

60%

96%*based on direct chart audit

We opened the champagne too soon!

72%

Slide courtesy of Dr. William Geerts.

Multicomponent Toolkit for Canadian Hospitals

•Best practices in VTE prophylaxis

•Clinical order set•Audit material•Health Professional

education material•Patient education

material

The Content

• Reginald E. Smith, PharmD, ACPR, (Chair) Clinical Pharmacy Specialist, Thrombosis Clinic, BC

• William Geerts, MD, FRCPC, National lead, VTE Prevention, Safer Healthcare Now! Thromboembolism Specialist; Professor of Medicine, University of Toronto, ON

• Artemis Diamantouros, BScPharm, MEd, National Coordinator, VTE Prevention, Safer Healthcare Now!; KT Pharmacist, ON

• Glenn Whiteway, BScPharm, PharmD, Pharmacy Clinical Manager; Adjunct Professor, Dalhousie University, NB

• Mary Pederson, BScPharm, Clinical Practise Leader, AB• Patrick Robertson, BSP, PharmD, Manager Pharmacy Services,

SK• William Semchuk, MSc, PharmD, FCSHP, Manager Pharmacy

Services, SK• Ritesh Mistry, MD, CCFP, Hospitalist; Clinical Assistant Professor,

McMaster University, ON

Developed by Canadian experts

• Sylvie Desmarais, MD, FRCPC, CSPQ, Internal and Vascular Medicine Internist, QC

• James Douketis, MD, FRCPC, FACP, FCCP, Professor, McMaster University, ON

• Jeannine Kassis, MD, FRCPC, Hematologist; Professor of Medicine, Université de Montréal, QC

• Robin McLeod, MD, FRCSC, FACP, Professor of Surgery and Health Policy, University of Toronto, ON

• Otto Moodley, MD, FRCPC, Clinical Hematologist, SK

Reviewed by Canadian experts

Prevention of VTE in Hospitalized Patients: Summary of Good Practice

Weight Based vs. Fixed Dosing• fixed doses of LMWH in a prefilled syringe (i.e.

tinzaparin 4 500 U subcutaneously once daily) is the simplest regimen for most patients.

• obese patients (>100 kg, BMI>35 kg/m2) require higher doses of LMWH than the non-obese

• use fixed dosing for patients between 50-100 kg and adjust dosing for others

Prevention of VTE in Hospitalized Patients:

Summary of Good Practice

Weight Dalteparin Dose

Enoxaparin Dose

Tinzaparin Dose

<40 kg 2 500 U SC once daily

30 mg SC once daily

3 500 U SConce daily

40-100 kg 5 000 U SC once daily

40 mg SC once daily

4 500 U SC once daily

101-150 kg 5 000 U SC BID 40 mg SC BID 10 000 U SC once daily

151-200 kg 40 U/kg SC BID 0.4 mg/kg SC BID 14 000 U SC once daily

Prevention of VTE in Hospitalized Patients:

Summary of Good PracticeeGFR >30 mL/min

In patients with impaired renal function (<30 mL/min):Dalteparin: no dose adjustment is required.Enoxaparin: a dosage adjustment is recommended since enoxaparin appears to accumulate in this patient group and may increase risk of bleeding.Tinzaparin: no dose adjustment of tinzaparin at prophylaxis doses is needed in patients with impaired renalfunction1, renal failure2,3, or on hemodialysis2,3 .

Embed Prophylaxis into Order Sets

Guidelines for Prevention of VTE

*Use clinical judgment to weigh the risk of venous thromboembolism versus the risk of bleeding.*Use clinical judgment to weigh the risk of venous thromboembolism versus the risk of bleeding.

Contraindications to LMWHs:

Awareness