1. Venous Thromboembolism Prophylaxis and Management in the Medical Patient at Sisters of Charity Hospital Jeffrey Parker, DO Dr. Nashat Rabadi, MD Sisters of Charity Hospital Buffalo, New York

2. Case Presentation Hospital Course –60 year old female directly admitted to the hospital with acute on chronic CHF –Over the phone orders were given to nurse by primary doctor –CHF standardized form not used –DVT prophylaxis form not used

3. Case Presentation Appropriate CHF treatment given Pts symptoms improve On third hospital day, patient complains of left calf pain and increased swelling Left DVT diagnosed by venous doppler Heparin and Coumadin started

4. Case Presentation Why did the patient develop a DVT?

5. Presentation Overview VTE Background VTE Prophylaxis and Treatment Joint Commission VTE Safety Guidelines Research Question and Methods

6. Venous Thromboembolism Deep vein thrombosis (DVT) and acute pulmonary embolism (PE) are two manifestations of the same disorder, venous thromboembolism Over 90 percent of cases of acute PE are due to emboli emanating from the proximal veins of the lower extremities

7. VTE Morbidity and Mortality DVT and PE represent a major health problem Hospitalized patients have a 150-fold increased absolute risk compared to patients in the community 10% of hospital deaths are due to PE In-hospital case-fatality rate of VTE is 12%

8. VTE Risk Factors Age Immobilization Surgery within the last three months Stroke Family history History of venous thromboembolism Malignancy Preexisting respiratory disease Congestive heart failure Oral contraceptives

9. VTE Risk Factors Nephrotic syndrome Inflammatory bowel disease Sepsis Hypercoaguable state Additional identified in women: –Obesity –Heavy Cigarette smoking –Hypertension Patients with Idiopathic PE: –Factor V Leiden mutation –Increased factor VIII

10. VTE Risk Factors The greater the number of risk factors a person has, the greater risk of developing a DVT!

11. VTE Prophylaxis Ambulation Arteriovenous foot pumps Sequential compression devices Elastic stockings Warfarin Unfractionated Heparin (UFH) Low Molecular Weight Heparin (LMWH) Fondaparinux IVC filter

12. VTE Prophylaxis The Seventh ACCP Consensus Conference on Antithrombotic Therapy recommends the use of either LMWH or low dose unfractionated heparin (LDUH) for VTE prophylaxis in acutely ill hospitalized patients without contraindications: Congestive heart failure or severe respiratory disease Confined to bed and have ≥1 additional risk factors Upon admission to a critical care unit

13. VTE Prophylaxis - LDUH 2007 study done comparing BID vs TID heparin dosing for VTE prophylaxis in the general medical population * Meta-analysis of 12 randomized controlled studies comparing BID or TID heparin dosing Concluded that TID dosing is likely superior to BID UFH for VTE prevention in hospitalized medical patients *King, C, et al. Twice vs Three Times Daily Heparin Dosing for Thromboembolism Prophylaxis in the General Medical Population.Chest 2007;131;507-516.

14. VTE Prophylaxis/Treatment Background Evidence-based DVT/PE guidelines for prophylaxis and treatment are not being routinely followed High risk patients are not receiving appropriate VTE prophylaxis Patients diagnosed with VTE are not receiving appropriate treatment Occurring at both academic and community hospitals in the United States

15. VTE Prophylaxis Background “…doctors are not doing enough to prevent DVT cases.”

16. VTE Prophylaxis Background A prospective registry of 5,451 patients with ultrasound-confirmed deep vein thrombosis Among hospitalized patients who had developed DVT, only 42% had received prior prophylaxis despite multiple risk factors, particularly in non- surgical patients Goldhaber S, Tapson V. A prospective registry of 5,451 patients with ultrasound-confirmed deep vein thrombosis. The American Journal of Cardiology 2004;93:259-262

17. Why is Prophylaxis Underused? Inconsistencies, conflicts, and ambiguities within the many different guidelines available Some physicians may be unaware of the current guidelines Some physicians may not believe the evidence for the guidelines is adequate Belief that VTE incidence in hospitalized and postoperative patients is too low to warrant routine prophylaxis

18. Why is Prophylaxis Underused? (cont) Concern that patients will be at risk for bleeding complications associated with pharmacologic prophylaxis Concern that patients will be at risk for heparin- induced thrombocytopenia (HIT) Lack of awareness that broad application of prophylaxis may be cost-effective Perception that VTE is not a significant problem in an individual physician’s practice

19. VTE Prophylaxis Reliance on symptoms or signs of early DVT is unreliable strategy to prevent VTE Routine screening of patients for asymptomatic DVT: – Logistically difficult – Not cost effective – Not effective in preventing clinically important VTE events

20. Consequences of Inadequate VTE Prophylaxis Increased morbidity and mortality Costly diagnostic testing Cost of therapeutic anticoagulation therapy Potential bleeding complications from therapy Delayed hospital discharge Increased future risk of recurrent VTE

21. VTE Prophylaxis: An Important Healthcare Priority Agency for Healthcare Research and Quality: –VTE prophylaxis top-ranked evidence-based safety practice National Quality Forum (NQF): –Top 30 practices to reduce risk – Evaluate VTE risk, use clinically appropriate prophylaxis

22. VTE Prophylaxis: An Important Healthcare Priority Joint Commission designated DVT as one of the “most common preventable causes of death in hospitals” –Estimated 60-70% of patients needing prophylaxis don’t receive it” American College of Chest Physicians Guidelines –Gives anticoagulant prophylaxis in medical patients a grade 1A recommendation

23. Cost Burden of VTE DVT and PE diagnosis and treatment costs in the U.S. are estimated to be as much as $15.5 billion annually MacDougall DA, et. Al. Am J Health-Syst. Pharm. 2006;63(Suppl 6):s5-15 Cundiff DK. Medscape General Medicine. 2004;6(3):5.

24. Joint Commission The following measures were developed by the Joint Commission under the guidance of NQF’s ‘Prevention and Care of VTE’ project and are currently being pilot tested

25. Joint Commission VTE Safety Guidelines 1)VTE Risk Assessment/Prophylaxis within 24 hours of Hospital Admission 2)VTE Risk Assessment/Prophylaxis within 24 hours of Transfer to ICU 3)Documentation of Inferior Vena Cava Filter Indication 4)VTE Patients with Overlap Therapy

26. Joint Commission VTE Safety Guidelines (cont) 5)VTE Patients Receiving Unfractionated Heparin with Platelet Count Monitoring 6)VTE Patients Receiving Unfractionated Heparin Management by Nomogram/Protocol 7)VTE Discharge Instructions 8)Incidence of Potentially Preventable Hospital Acquired VTE

27. VTE Treatment in Hospital Initiate treatment with full dose LMWH, UFH, or fondaparinux for at least 5 days and until the INR is > 2.0 for 24 h (unless contraindicated) Initiate Coumadin treatment together with LMWH, UFH, or fondaparinux on the first treatment day rather than delayed initiation (unless contraindicated) Therapeutic INR of 2 - 3

28. VTE Treatment in Hospital In patients with acute DVT, early ambulation is preferred to initial bed rest when this is feasible Bridging therapy with LMWH is indicated –INR is sub-therapeutic at discharge –Inadequate overlap therapy

29. Research Question Are high risk patients receiving appropriate VTE prophylaxis at Sisters Hospital? Are the standardized admission order forms being utilized at Sisters Hospital? What diagnostic modalities are being utilized at Sisters Hospital to diagnose VTE?

30. Research Question (cont) Is the treatment for VTE appropriate at Sisters of Charity Hospital with regards to: –Type of anticoagulation –Complications due to treatment –Overlap therapy –Appropriate bridging therapy –Length of hospital stay

31. Methods Retrospective chart review of patients diagnosed with and admitted to the hospital from 1/08 with: –CHF –Pneumonia –Known cancer (lung, colon, ovarian)

32. Methods (cont) Each chart was reviewed for: –Appropriate DVT prophylaxis –DVT prophylaxis sheet completed –Standardized admission forms completed if applicable

33. Methods (cont) Retrospective chart review of patients diagnosed with VTE from January 2008 – present at Sisters of Charity Hospital

34. Methods (cont) Appropriate treatment Coumadin start date Appropriate overlap therapy Therapeutic INR at discharge Family History Complications from treatment Hypercoaguable workup done DVT and PE standardized order sheets completed

35. Methods (cont) Compare 2006 and 2009 VTE Prophylaxis and Management Data Comparison

36. VTE Prophylaxis Research Data

37. CHF VTE Prophylaxis (n = 50) % of CasesNumber of Cases UFH Q838%19 LMWH26%13 SCD’s0%0 Warfarin22%11 UFH Q124%2 No Prophylaxis10%5 Resident Following58%29 DVT Sheet Complete 58%29 CHF Sheet Complete 74%37

38. CHF VTE Prophylaxis

39. Pneumonia VTE Prophylaxis (n = 50) % of CasesNumber of Cases UFH Q856%28 LMWH 40mg14%8 SCD’s6%3 Warfarin0%0 UFH Q1216%7 No Prophylaxis14%7 Resident Following52%26 DVT Sheet Complete44%22 Pneumonia Sheet Complete 68%34

40. Pneumonia VTE Prophylaxis

41. Malignancy VTE Prophylaxis n = 50 (lung, colon, ovarian) % of CasesNumber of Cases UFH Q842%21 LMWH 40mg14%7 SCD’s6%3 Warfarin0%0 UFH Q1220%10 No prophylaxis18%9 Resident Following18%9 DVT Sheet Complete36%18

42. Malignancy VTE Prophylaxis

43. 2006 vs 2009 Appropriate VTE Prophylaxis Comparison Medical Condition 2006 (n=25) 2009 (n=50) CHF82%86% Pneumonia88%70% Malignancy84%62%

44. Venous Thromboembolism Management Data

45. Patient Population (n = 80) Gender% of CasesAverage Age Male45%60 Female55%59

46. Diagnoses (n = 80) DiagnosisNumber of Cases DVT28 (35%) PE35 (44%) DVT & PE17 (21%)

47. Diagnostic Modalities Diagnostic Test% of Cases Doppler28 (35%) CT scan28 (35%) Doppler + CT scan15 (19%) Doppler + d-dimer1 (1.3%) CT scan + d-dimer3 (4%) VQ Scan + Doppler1 (1.3%) V/Q scan5 (5%)

48. Standard Order Sheets Standard Order Sheet% Complete DVT Prophylaxis39 (49%) *80 applicable cases PE Treatment18 (35%) *52 applicable cases 26% of cases were followed by residents

49. Hypercoaguable Workup # of Cases Done 32 (40%) Not Done 48 (60%) 4 cases positive: –Lupus anticoagulant x 2 –Factor V Leiden –Factor II Mutation

50. Family History # of Cases Positive for DVT and/or PE 9 (11%) Negative48 (60%) Unknown/Not Addressed 23 (29%)

51. Recent Hospitalization History Recent Hospitalization – 21 patients –18 of the hospitalized patients had medical conditions that placed them at high risk for VTE Surgery Pneumonia Ulcerative colitis DVT PE

52. VTE Treatment Treatment# of Cases UFH54 (70%) *77 cases applicable LMWH23 (29%) *77 cases applicable IVC Filter + anti-coag13 (16%) *77 cases applicable Thrombolytics0 (0%) Anticoagulation Contraindicated 3 (4%) * Due to GI Bleeding Complications from anticoagulation occurred in 7 cases –6 lower GI bleeding –1 heparin induced thrombocytopenia

53. Anticoagulation Management Anticoagulation Mgnt.Days Average Coumadin Start Date 1.7 Average Day INR Therapeutic 4.2

54. Anticoagulation Management (cont) Overlap Treatment# of Cases Therapeutic Discharge INR w/o Adequate Overlap Treatment 12 Therapeutic Discharge INR + Adequate Overlap Treatment 36

55. Anticoagulation Management (cont) Overlap Treatment# of Cases Non-therapeutic INR w/ Overlap Tx on Discharge 11 Non-therapeutic INR w/o Overlap Tx on Discharge 8

56. Anticoagulation Overlap Therapy

57. 2006 vs 2009 VTE Management 20062009 Average Coumadin Start Date 2.11.7 Average Day INR Therapeutic 5.94.2 Inadequate Overlap Tx 53%30%

58. Measures to Improve VTE Prophylaxis and Treatment at Sisters Hospital Physician and Nursing Education Public Education Utilize DVT Prophylaxis Form Utilize Standardized Admission Forms Pharmacy Involvement Soarian System Integration