PREVENTING HOSPITAL-ACQUIRED
VENOUS THROMBOLISM (VTE)

GOAL: Eliminate preventable cases of hospital-acquired venous thromboembolic disease from all inpatient units in New Hampshire hospitals over the next 12-18 months.

METHODOLOGY: Increase the rates of appropriate venous thromboembolism (VTE) prophylaxis

RATIONALE: Venous thromboembolism is a significant cause of morbidity and mortality in hospitalized patients. Pulmonary Embolism in particular is a dangerous condition with an exceeding high mortality rate. Multiple clinical trials have provided irrefutable evidence that primary thromboprophylaxis reduces the incidence of deep vein thrombosis and pulmonary embolus. For these reasons, VTE prevention is a priority for the Joint Commission, Centers for Medicare and Medicaid Services (Meaningful Use and Surgical Care Improvement Project), Institute for Healthcare Improvement (IHI) and the National Quality Forum (NQF)

RECOMMENDATIONS: The Boards of the New Hampshire Hospital Association and Foundation for Healthy Communities recommends that all NH hospitals adopt the following:

A. Program Elements: All New Hampshire hospitals will:

• Assess all patients on admission for VTE risk
• Provide appropriate VTE prophylaxis, including pharmaceutical and mechanical approaches based on national guidelines such as:
  • Surgical patients with procedures designated in SCIP measures
  • Intensive care ventilated patients as part of the VAP bundle
  • All other patients assessed to be at risk (based on ACCP8 Guidelines, The Joint Commission core measure sets among others)

B. Protocol: All New Hampshire hospitals should have an institution-wide evidence-based, system-supported protocol on VTE prophylaxis which includes diagnostic, preventive, and therapeutic algorithms. It should consist of the following components:

• VTE Risk Assessment which providers will use to stratify the patient to a specific VTE risk level
• Linked menu of appropriate prophylaxis options using electronic or written decision support which allows providers to choose the right VTE prophylaxis
• Contraindications to pharmacologic prophylaxis which provides decision support

C. Measures: New Hampshire hospitals will monitor their progress and be accountable for their care using the following measures:

• Venous Thromboembolism Prophylaxis
  • Percent of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission.

• Incidence of Potentially-Preventable Venous Thromboembolism

  • Percent of patients diagnosed with confirmed VTE during hospitalization(not present on arrival) who did not receive VTE prophylaxis between hospital admission and the day before the VTE diagnosis testing order date.

Resources and Key Recommendations:
Agency for Healthcare Research and Quality
    Diagnosis and Treatment of Deep Vein Thrombosis and Pulmonary Embolism

American College of Chest Physicians (ACCP)
    The Eighth ACCP Conference on Antithrombotic and Thrombolytic Therapy (Abstract / Full Report)

Among the key recommendations in this chapter are the following: we recommend that every hospital develop a formal strategy that addresses the prevention of VTE (Grade 1A). We recommend against the use of aspirin alone as thromboprophylaxis for any patient group (Grade 1A), and we recommend that mechanical methods of thromboprophylaxis be used primarily for patients at high bleeding risk (Grade 1A) or possibly as an adjunct to anticoagulant thromboprophylaxis (Grade 2A).

For patients undergoing major general surgery, we recommend thromboprophylaxis with a low-molecular-weight heparin (LMWH), low-dose unfractionated heparin (LDUH), or fondaparinux (each Grade 1A). We recommend routine thromboprophylaxis for all patients undergoing major gynecologic surgery or major, open urologic procedures (Grade 1A for both groups), with LMWH, LDUH, fondaparinux, or intermittent pneumatic compression (IPC).

For patients undergoing elective hip or knee arthroplasty, we recommend one of the following three anticoagulant agents: LMWH, fondaparinux, or a vitamin K antagonist (VKA); international normalized ratio (INR) target, 2.5; range, 2.0 to 3.0 (each Grade 1A). For patients undergoing hip fracture surgery (HFS), we recommend the routine use of fondaparinux (Grade 1A), LMWH (Grade 1B), a VKA (target INR, 2.5; range, 2.0 to 3.0) [Grade 1B], or LDUH (Grade 1B). We recommend that patients undergoing hip or knee arthroplasty or HFS receive thromboprophylaxis for a minimum of 10 days (Grade 1A); for hip arthroplasty and HFS, we recommend continuing thromboprophylaxis > 10 days and up to 35 days (Grade 1A). We recommend that all major trauma and all spinal cord injury (SCI) patients receive thromboprophylaxis (Grade 1A). In patients admitted to hospital with an acute medical illness, we recommend thromboprophylaxis with LMWH, LDUH, or fondaparinux (each Grade 1A). We recommend that, on admission to the ICU, all patients be assessed for their risk of VTE, and that most receive thromboprophylaxis (Grade 1A).

Society of Hospital Medicine:
    Preventing Hospital Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement