Why VTE prophylaxis needs to start on hospital admission

Dr Agnes Yuen

VTE prophylaxis during hospital admissions is sub-optimal with implications for both inpatient and post-discharge hospital-associated VTEs, Australian research shows.

According to a Melbourne study presented at the ISTH 2020 Virtual Congress, post-discharge hospital-associated VTEs are also more prevalent than expected.

The retrospective study identified 81 adult inpatient VTEs at Monash Health during the study period between January 2018 and May 2019.

An audit of 948 patients with VTE discharge coding identified 57 cases of post-discharge hospital-associated VTEs that are not routinely captured. Cases were included if they occurred between 48 hours and 90 days after an index hospital admission.

Most index admissions were medical (61%) and there was a median of 19 days between index admission and readmission.

The study found VTE prophylaxis was concordant with guidelines during the index admission in only 51% of cases.

Non-adherence included delayed prescription (5%), interruptions (23%), no prescriptions (14%) and inadequate prescriptions such as inappropriately dose-reduced enoxaparin (7%).

Dr Agnes Yuen, a haemostasis and thrombosis fellow at Monash Health, told the limbic that VTE prophylaxis was not being prescribed as per guidelines.

“Sometime it might be due to system errors because patients often have surgeries booked for the next day and they get VTE prophylaxis withheld at night and then they get bumped from surgery and rebooked and bumped again … then you can have a few days with no VTE prophylaxis on board.”

She said VTE prophylaxis was also often charted after a few days in hospital rather than being prescribed promptly upon admission.

Overall about 35% of the VTEs were deemed potentially preventable.

Dr Yuen said the hospital’s VTE committee had instigated a number of changes to improve VTE prophylaxis.

“At Monash we have actually changed the time of administration of enoxaparin to 4pm and that means that it doesn’t have to be withheld for a procedure in the morning. That’s less dose interruption,” she said.

“We’ve also had increasing education of junior staff, pop-ups on the electronic medical records to prompt VTE prophylaxis and ongoing audits of inpatient VTE.”

She said data on post-discharge hospital-associated VTE was quite difficult to collect as patients who presented to their GPs or to a different hospital network with a DVT or PE could be missed.

“It could be a tip of the iceberg scenario where our stats only reflect inpatients diagnosed with VTE at the moment … we are not capturing it [post-discharge hospital-associated VTE] in our current research methods.”

“Post-discharge hospital-associated VTE is actually more prevalent than what we previously thought and therefore adherence to prophylaxis guidelines and thinking about the patients VTE risk on admission and also post-discharge is important.”

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