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A Different Strategy to Help Prevent VTE in Trauma Patients

A Different Strategy to Help Prevent VTE in Trauma Patients

Venous thromboembolism (VTE)—consisting of pulmonary embolism (PE) and DVT—is one of the most common and deadliest complications experienced by trauma patients admitted to hospitals. According to recent estimates, trauma is the leading killer of young people in the United States. Other studies suggest that at least 100,000 people die from PE alone every year. In light of the incidence of these events, the AHRQ recently placed interventions to improve VTE prophylaxis on its top 10 list of patient safety practices that are strongly encouraged. Changing the Approach of VTE Prophylaxis “Currently, healthcare practitioners use a complex flow diagram for determining the most appropriate strategies when providing VTE prophylaxis,” explains Elliott R. Haut, MD, FACS. For a study, Dr. Haut and colleagues converted the complex algorithm into a shorter clinical decision support-enabled VTE order set that was built into a computerized provider order entry system (CPOE). The converted algorithm was used at the point of care by trauma services providers at the Johns Hopkins Hospital in the analysis. For the intervention, clinicians checked off appropriate boxes on a short checklist (Table) based on patients’ VTE risk factors and contraindications to pharmacologic VTE prophylaxis. The CPOE system integrated this information into an evidence-based algorithm to stratify patients’ VTE risk. The system then suggested the optimal decision for an appropriate VTE prophylaxis regimen. “Using the order set was mandatory for all adult trauma patients in our study,” adds Dr. Haut, whose research was published in JAMA Surgery. The study team compared compliance with guideline-appropriate VTE prophylaxis during the year prior to implementing the order set with the 3 years after implementation. Increased...

Smoking, VTE Risk, & Surgery

The risk of venous thromboembolism (VTE) appears to be higher for current smokers when compared with never smokers among patients undergoing surgery in the 12 weeks after their procedure. The British research team also found that risk for VTE was significantly higher for heavier smokers than lighter smokers. Abstract: Circulation, March 12, 2013...

Venous Thromboembolism Deadly in COPD Patients

Patients with COPD appear to be at increased risk of in-hospital and 30-day mortality following a diagnosis of venous thromboembolism (VTE), according to Massachusetts-based study. Among those diagnosed with VTE, in-hospital mortality rates were 6.8% for those with COPD and 4.0% for those without. Mortality within 30 days of a VTE diagnosis was 12.6% for those with COPD and 6.5% for those without the respiratory disease. Abstract: American Journal of Medicine, October...

Managing Pulmonary Embolism in the ED

Venous thromboembolism (VTE), which includes DVT and pulmonary embolism (PE), is the third leading cause of cardiovascular death among Americans and is especially fatal if these events go undiagnosed and are not treated promptly. PE is most frequently diagnosed in the ED and is associated with 14- and 30-day mortality rates of about 10% and 20%, respectively. Research has shown that a prompt diagnosis of acute PE—within 48 hours of ED arrival—is associated with improved outcomes. Factors Associated with Delays in PE Diagnosis My colleagues and I previously reported that administra­tion of anticoagulants within 24 hours of ED arrival is as­sociated with reduced mortality. Current guidelines from the American College of Chest Physicians recommend that anticoagulation be initiated even before a confirmed diag­nosis, when the probability of PE is believed to be high. However, studies have indicated that there is potential for significant delays from the time of symptom onset to PE diagnosis in the ED. A prompt diagnosis of acute PE—within 48 hours of ED arrival—is associated with improved outcomes. In an effort to better understand the factors associated with timing of a PE diagnosis in the ED, my colleagues and I conducted a review that was published in the January 2012 Journal of Emergency Medicine. Following univariate and multivariate analyses, we found that the following factors appeared to be associated with delays in PE diagnoses of more than 12 hours: Age older than 65. Concurrent cardiovascular disease (CVD). Morbid obesity (BMI >40 kg/m2). A history of recent immobility (eg, recent surgery) and pre­sentation to the ED with tachycardia were factors associ­ated with a relatively early diagnosis of...

Reducing VTE Risk After Hip & Knee Replacement

Venous thromboembolism (VTE), which encompasses deep vein thrombosis (DVT) and pulmonary embolism (PE), is one of the most common reasons for readmission following primary hip or knee replacement surgery. However, recent studies suggest that only 0.7% to 0.9% of patients undergoing hip or knee replacements require rehospitalization because of VTE in the first 3 months after surgery. “These surgeries put patients at risk for thromboembolic disease because they affect multiple aspects of Virchow’s triad,” explains Joshua J. Jacobs, MD. Virchow’s triad consists of hypercoagulability, venous stasis, and injury to the vascular endothelium. All three components of the triad can be present following hip or knee replacement surgery and predispose individuals to thrombosis, according to Dr. Jacobs. “DVT occurs in about 37% of patients following primary hip or knee replacement surgery who have not been treated with prophylactic agents. The rate of clinically symptomatic VTE events is far less, but VTE should be an important concern of orthopedic surgeons performing these procedures.” New Guidelines on Preventing VTE Dr. Jacobs chaired a workgroup that updated guidelines from the American Academy of Orthopaedic Surgeons (AAOS) on preventing VTE in patients undergoing elective hip and knee arthroplasty. The guidelines were released on September 24, 2011 and are available for free at www.aaos.org/guidelines. “The AAOS felt it was necessary to update these guidelines for the first time since 2007 because of the increasing availability of study data that impacted the previous recommendations and to maintain inclusion in the AHRQ’s National Guideline Clearinghouse, which requires an update every 5 years,” says Dr. Jacobs. The American College of Chest Physicians has also published guidelines on VTE...
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