Venous thromboembolism prevention guidelines for medical inpatients: Mind the (implementation) Gap.
J Hosp Med. 2013 Aug 27;
Authors: Maynard G, Jenkins IH, Merli GJ
Abstract
BACKGROUND: Hospital-associated nonsurgical venous thromboembolism (VTE) is an important problem addressed by new guidelines from the American College of Physicians (ACP) and American College of Chest Physicians (AT9).
METHODS: Narrative review and critique.
RESULTS: Both guidelines discount asymptomatic VTE outcomes and caution against overprophylaxis, but have different methodologies and estimates of risk/benefit. Guideline complexity and lack of consensus on VTE risk assessment contribute to an implementation gap. Methods to estimate prophylaxis benefit have significant limitations because major trials included mostly screening-detected events. AT9 relies on a single Italian cohort study to conclude that those with a Padua score ≥4 have a very high VTE risk, whereas patients with a score <4 (60% of patients) have a very small risk. However, the cohort population has less comorbidity than US inpatients, and over 1% of patients with a score of 3 suffered pulmonary emboli. The ACP guideline does not endorse any risk-assessment model. AT9 includes the Padua model and Caprini point-based system for nonsurgical inpatients and surgical inpatients, respectively, but there is no evidence they are more effective than simpler risk-assessment models.
CONCLUSIONS: New VTE prevention guidelines provide varied guidance on important issues including risk assessment. If Padua is used, a threshold of 3, as well as 4, should be considered. Simpler VTE risk-assessment models may be superior to complicated point-based models in environments without sophisticated clinical decision support. Journal of Hospital Medicine 2013;. © 2013 Society of Hospital Medicine.
PMID: 23983041 [PubMed - as supplied by publisher]
In my experience we have gone to the extreme of providing pharmacologic DVT prophylaxis for all medicine patients who are not actively bleeding or coagulopathic. This is the easiest path in our CPOE. Many patients are likely low risk and should not be getting heparin or LMWH shots.
Padua prediction scale is flawed, but at least is somewhat evidence based. If you look at the patients who suffered VTE, all are at least 70, or have active cancer.
I think the best thing to do for our medicine patients is make them ambulate several times a day (with assistance if needed).