VTE prophylaxis order set development
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VTE Prophylaxis • Keep it simple, without overlooking important risk factors – Goal is to prevent potentially preventable VTE • Will need to utilize some form of thromboprophylaxis in at risk patients • Will need to document that a patient is at low risk and requires no VTE prophylaxis other than early ambulation. • Will need to document that pharmacologic and mechanical thromboprophylaxis are contraindicated in the medical record in a patient at risk of VTE • Utilizing the ACCP thromboprophylaxis guidelines • ACCP 9th Edition • •Separated the VTE prevention chapters into three primary groups: non-surgical ( medical) groups, orthopedic surgical, non-orthopedic surgical • •For the Non-surgical and Non-orthopedic surgical chapters, a primary shift is towards an individualized approach of risk assessing the patients’ bleeding risk factors as well as their VTE risk factors for the appropriate TP strategy • Kahn et al. CHEST 2012; 141:(2 Suppl): e195S-226S • Falck-Ytter et al. CHEST 2012; 141:(2 Suppl): e278S-325S • Gould et al. CHEST 2012; 141:(2 Suppl): e227S-277S
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Transcript of VTE prophylaxis order set development
VTE Prophylaxis
• Keep it simple, without overlooking important risk factors– Goal is to prevent potentially preventable VTE
• Will need to utilize some form of thromboprophylaxis in at risk patients • Will need to document that a patient is at low risk and requires no VTE prophylaxis other than early ambulation.• Will need to document that pharmacologic and mechanical thromboprophylaxis are contraindicated in the medical record
in a patient at risk of VTE
• Utilizing the ACCP thromboprophylaxis guidelines• ACCP 9th Edition• •Separated the VTE prevention chapters into three primary groups: non-surgical ( medical) groups, orthopedic surgical,
non-orthopedic surgical• •For the Non-surgical and Non-orthopedic surgical chapters, a primary shift is towards an individualized approach of risk
assessing the patients’ bleeding risk factors as well as their VTE risk factors for the appropriate TP strategy• Kahn et al. CHEST 2012; 141:(2 Suppl): e195S-226S • Falck-Ytter et al. CHEST 2012; 141:(2 Suppl): e278S-325S • Gould et al. CHEST 2012; 141:(2 Suppl): e227S-277S
ACCP Antithrombotic Recommendations Medical
• At risk for VTE, low bleed risk• •Low molecular weight heparin (LMWH) (1B) • •Low dose unfractionated heparin (LDUH) BID or TID * (1B) • •Fondaparinux (1B
• At risk for VTE, high bleed risk or actively bleeding• •Optimal use of graduated compression stockings (GCS) or • intermittent pneumatic compression (IPC) (2C) • •When bleeding risk subsides and if VTE risk persists, • pharmacologic TP as above. (2B)• Kahn et al. CHEST 2012; 141:(2 Suppl): e195S-226S
Risk Assessment model (RAM) for VTE
• ACCP 2012 recommendations utilized the Padua RAM. Any patient with a RAM> or = to 4 receives VTE prophylaxis.
Examples of order sets from other hospitals and tables to determine bleeding risk.
• Order set from Maynard. J Thromb Throbolysis (2010) 29:159-166
Example of a Risk Assesssment Model that contains both medical VTE risk factors and bleeding risk factors taken from a power point presentation by Kurt Mahan PharmD Director of Outcomes Research New Mexico Heart Institute, Clinical Assistant
Professor of Pharmacy University of New Mexico. Venous Thromboembolism Prevention: How to Make This Work
Example of table for absolute and relative contraindications to anticoagulant prophylaxisDobromirski, Cohen. Blood 2012 120:1562-1569
Active bleeding
Lumbar puncture/epidural/spinal anesthesia within the previous 4 hours or expected within the next 12 hoursConcurrent use of anticoagulants known to increase the risk of bleeding (eg, warfarin with INR > 2)Acquired bleeding disorders (eg, acute liver failure)Mucosal lesions (eg, active peptic ulceration, bronchiectasis)Acute stroke (within 24 hours)Thrombocytopenia (platelets < 75 × 109/L) Uncontrolled systolic hypertension (≥ 230/120 mmHg)Untreated inherited bleeding disorders (eg, hemophilia or von Willebrand disease) Dobromirski, Cohen. Blood 2012 120:1562-1569
Example of a table for contraindications to mechanical VTE prophylaxisDobromirski, Cohen. Blood 2012 120:1562-1569
Suspected or proven peripheral arterial diseasePeripheral neuropathy or other causes of sensory impairmentFragile skin, dermatitis, gangrene, or recent skin graftCardiac failure or severe leg edemaAllergy to material or inability to fit stocking
Example of RAM and order set
Example of a RAM (Caprini model) and VTE prophylaxis orders based on a surgical model form the University of Michigan Health System
Examples found on the Society of Hospital Medicine website ordersets and protocolshttp://www.hospitalmedicine.org/ResourceRoomRedesign/RR_VTE/html_VTE/12ClinicalTools/02_Ordersets.cfm
More examples of ordersets and protocols from the Society of Hospital Medicine websitehttp://www.hospitalmedicine.org/ResourceRoomRedesign/RR_VTE/html_VTE/12ClinicalTools/02_Ordersets.cfm
More examples of ordersets and protocols from the Society of Hospital Medicine websitehttp://www.hospitalmedicine.org/ResourceRoomRedesign/RR_VTE/html_VTE/12ClinicalTools/02_Ordersets.cfm
