Venous Thromboembolism preventive strategies in hospitalized patients

VTE Prophylaxis Venous Thromboembolism Prevention Strategies In Hospitalized Patients Jung-Ah Lee, PhD, RN, Brenda K. Zierler, PhD, RN, RVT, Robb W. Glenny, MD, Ann K. Wittkowsky, PharmD, Gwen van Servellen, PhD, RN, and Alpesh N. Amin, MD, MBA Abstract • Objective: To provide an overview of venous throm- boembolism (VTE) prevention strategies, including a review of current quality initiatives. • Methods: A review of relevant journal articles and web sites related to VTE prevention and risk as- sessment was conducted. • Results: VTE is a major source of morbidity and mortality world-wide and considered to be the most common preventable cause of hospital death. Evidence-based consensus guidelines on throm- boembolic prophylaxis have been available inter- nationally for decades, yet VTE prophylaxis is often underutilized or inappropriately used. Recommenda- tions for VTE prophylaxis include early ambulation or education for low-risk patients and pharmacologic prophylaxis using anticoagulants for moderate- or high-risk patients. Mechanical prophylaxis mea- sures are recommended for patients at high risk of bleeding as they are not eligible for pharmacologic prophylaxis. Systems approaches to improving VTE prophylaxis have been developed, and agencies have established quality measures to improve care of this condition. • Conclusion: Health care organizations should ensure that all hospitalized patients receive VTE risk assessment upon admission and after a major event and that appropriate interventions for VTE prevention are taken. An evaluation of processes used in the assessment and prevention of VTE and subsequent clinical outcomes should be integrated with quality improvement and patient safety mea- sures. V enous thromboembolism (VTE), manifesting as deep vein thrombosis (DVT) and pulmonary embo- lism (PE), is the third most common cardiovascular disease after myocardial infarction and stroke [1]. It affects 350,000 to 600,000 Americans annually and causes at least 66 JCOM February 2011 Vol. 18, No. 12 100,000 deaths [2]. Over half of affected individuals develop VTE in the hospital or within 30 days of hospital discharge [3]. The total annual health care costs attributable to VTE in the United States are $2 to $10 billion [4]. Many VTE events are preventable, and evidence-based guidelines for preven- tion have been published. However, despite the availability of guidelines, VTE prophylaxis is underutilized. The current paper provides an overview of strategies for VTE prophy- laxis including systems-supported strategies for improving VTE care in health care settings. • What are risk factors for VTE? In 1884, Rudolf Virchow first described the pathophysiol- ogy of VTE [5]. Virchow identified 3 main etiologic factors for VTE: venous stasis, endothelial damage, and hyper- coagulability (Virchow’s triad). Other important findings described by Virchow and others during this era were that thrombi commonly occur within the lower extremity deep veins and less commonly in the vena cava or upper extremity deep veins [5]. During the next century, many risk factors for VTE were identified. The most common inherited (genetic) risk factors for VTE are factor V Leiden and the prothrombin gene mutation [6]. The most common acquired (nongenetic) risk factor for VTE is anticardiolipin syndrome [6]. A list of the risk factors for VTE is presented in Table 1 [7]. Risk Assessment All hospitalized adult patients, particularly elderly patients, patients with cancer, and patients undergoing major sur- gery, should be assessed for VTE risk. Patients should be From the University of California – Irvine, Irvine, CA (Drs. Lee and Amin); the University of Washington, Seattle, WA (Drs. Zierler, Glenny, and Wittkowsky), and the University of California – Los Angeles (Dr. van Servellen). www.jcomjournal.com