Cost-Consciousness Assignment

Ollie Ross

DSR 2

Adherence to ACP DVT prophylaxis guidelines

• Objective: Evaluate adherence to ACP DVT prophylaxis guidelines in a LBVA ward team and determine if excessive prophylaxis is being utilized

ACP Guidelines

• Venous Thromboembolism Prophylaxis in Hospitalized Patients: A Clinical Practice Guideline From the American College of Physicians. Qaseem, A., Chou, R., et al. Annals of Internal Medicine. 2011;155:625-632

ACP Recommendation 1

• ACP recommends assessment of the risk for thromboembolism and bleeding in medical (including stroke) patients prior to initiation of prophylaxis of venous thromboembolism (Grade: strong recommendation, moderate-quality evidence).

ACP Recommendation 1

• “Many risk assessment tools are available for estimating thromboembolism risk, but the current evidence is insufficient to recommend a validated tool”

• Note: ACCP recommends patients at low risk for DVT/PE require NO prophylaxis

Padua Risk Assessment Model

• 3 points: Cancer, past VTE, immobility, thrombophilic condition

• 2 points: Trauma or surgery in past month• 1 point: Age 70 or older, CHF, AMI, Ischemic

CVA, BMI 30 or greater, hormone use, acute infectious or rheumatologic disorder

• Score <4 considered Low Risk

ACP Recommendation 2

• ACP recommends pharmacologic prophylaxis with heparin or a related drug for venous thromboembolism in medical (including stroke) patients unless the assessed risk for bleeding outweighs the likely benefits (Grade: strong recommendation, moderate-quality evidence).

ACP Recommendation 3

• ACP recommends against the use of mechanical prophylaxis with graduated compression stockings for prevention of venous thromboembolism (Grade: strong recommendation, moderate-quality evidence).

ACP Recommendation 3

• “In patients at high risk for bleeding events or in whom heparin is contraindicated for other reasons, intermittent pneumatic compression may be a reasonable option, because evidence suggests that it is beneficial in surgical patients”

• “However, intermittent pneumatic compression has not been sufficiently evaluated as a stand-alone intervention in medical patients to reliably estimate benefits and harms”

Methods

• One LBVA ward team with over 10 patients was chosen at random

• EMR was reviewed to determine what DVT prophylaxis were ordered

• Patients were seen to determine if SCDs were in place

Results

• 11 patients; all Padua score 4 or greater• 6/11 had only heparin SQ ordered• 2/11 had only SCDs ordered (active bleeding/ surgery

planned), but SCDs were not in place (bilateral urostomy bags/ patient refusal)

• 1/11 had heparin SQ and SCDs ordered but SCDs were not in place

• 1/11 had coumadin (A-fib) and SCDs ordered and SCDs were in place

• 1/11 had INR >3 (cirrhosis) so no DVT ppx was ordered

Results

• 2/11 had both anticoagulation and SCDs ordered, but only 1/11 was actually receiving both

Take Home Point

• ACP DVT prophylaxis guidelines do not recommend simultaneous use of both anticoagulation and mechanical compression devices

• Simultaneous use of both anticoagulation and SCDs may be superfluous