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:

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