1. SCOPE of GUIDELINE:

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1 Page 1 of 35 CLINICAL PRACTICE GUIDELINE: Venous Thromboembolism (VTE) Prevention Guideline: Thromboprophylaxis AUTHORIZATION: VP, Medicine Date Approved: May 17, 2012 Date Revised: Vancouver Coastal Health (VCH) is acknowledged for their excellence in the development of this guideline which they have generously shared with Fraser Health. Fraser Health has adopted VCH s policy and guideline with minor adaptations to acknowledge differences in resources. Updated changes to the Guideline will be made as new evidence emerges and in conjunction with VCH. 1. SCOPE of GUIDELINE: This guideline provides supportive documentation for the Fraser Health Thromboembolism (VTE) Policy for hospitalized patients. It outlines the recommended thromboprophylaxis practice based on available evidence and practice standards on prevention of venous thromboembolism. This Guideline defines the approaches to be used for VTE assessment, bleeding assessment, the rationale for thromboprophylaxis recommendations, and roles and responsibilities of health care providers. The recommendations apply to most patients at risk for VTE. 1 This guideline is not intended to replace the physicians clinical judgment, which should be exercised in all cases to optimize the quality and safety of patient care. Physicians are advised to consult consensus guidelines for specific patient populations when presented with complex and unusual cases. It is important in these cases for patients and family members to be involved as appropriate with the decision making regarding thromboprophylaxis due to potential risks of providing or withholding thromboprophylaxis. The decision making process should be clearly documented in the patient s chart to ensure transparency, maximize patient safety and facilitate communication. 2. PURPOSE: To standardize and provide evidenced based risk assessment for thromboembolism and appropriate intervention for patients admitted to acute care. 3. RATIONALE: VTE comprises both deep vein thrombosis (DVT) and pulmonary embolism (PE) and is one of the most common and preventable complications of hospitalization. 1 Many risks factors for developing VTE have been identified (see Table 1), but the most common risk factor in hospitalized patients is immobility. Almost every hospitalized patient has at least one of these risk factors for VTE and most have multiple risk factors. 3,4 For additional information see VCH VTE Prevention Guideline: Thromboprophylaxis. Recommendations from Accreditation Canada s Required Organizational Practices (ROPs), Safer Heath Care Now (SHCN) and British Columbia s Clinical Care Management (CCM) challenge are directing organization-wide strategies to ensure all patients at risk receive appropriate thromboprophylaxis. 3,4,5 Author(s): Fraser Health CDST#: NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy. April 23, 2012

2 Page 2 of 35 CLINICAL PRACTICE GUIDELINE: Venous Thromboembolism (VTE) Prevention Guideline: Thromboprophylaxis AUTHORIZATION: VP, Medicine Date Approved: May 17, 2012 Date Revised: Table 1. Risk Factors for VTE 2 Age 60 years or over Active cancer or cancer treatment Previous VTE Critical Care admission Known thrombophilia First degree relative with VTE Varicose veins with phlebitis Estrogen-containing oral contraceptives Hormone replacement therapy One or more significant medical conditions Sepsis or severe acute infection Heart disease Respiratory pathology Inflammatory condition Rheumatological disease Nephrotic syndrome Antiphospholipid syndrome 4. DEFINITIONS Venous thromboembolism (VTE) is a thromboembolic event ( blood clot ) that develops within the venous system and included both deep vein thrombosis and pulmonary embolism. Deep vein thrombosis (DVT) is a thrombus ( blood clot ) occurring in one or deeper veins, especially in the legs, where it may produce leg swelling and/or pain. Pulmonary embolism (PE) is a thrombus that arises in a deep vein and that embolizes to one or more of the pulmonary arteries where it may result in breathlessness, chest pain, hemoptysis, syncope, or death. Thromboprophylaxis (TP) refers to the use of mechanical methods or anticoagulant medication to prevent VTE from developing in patients who are at risk EXPECTED OUTCOMES: 5.1. All hospitalized patients will be assessed and prescribed the most appropriate intervention by the most responsible physician (MRP) for VTE risk at the time of admission to hospital at the time of significant change in clinical status at the time of transfer from one type of care to another at discharge 5.2. Appropriate, evidence-based thromboprophylaxis will be provided to every hospitalized patient when indicated based on their risk of thrombosis, risk of bleeding, and available options at Fraser Health Authority. 1, 7 6. STEPS IN DECISION MAKING PROCESS: STEP 1: Assess risk for thromboembolism (see Table 2) STEP 2: Prescribe appropriate thromboprophylaxis using pre-printed order STEP 3: Document any deviation from recommended practices. Author(s): Fraser Health CDST#: NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy. April 23, 2012

3 Page 3 of 35 CLINICAL PRACTICE GUIDELINE: Venous Thromboembolism (VTE) Prevention Guideline: Thromboprophylaxis AUTHORIZATION: VP, Medicine Date Approved: May 17, 2012 Date Revised: 7. INTERVENTIONS Two major methods of thromboprophylaxis are available: pharmacological and mechanical. Pharmacological methods are well studied and consistently shown to produce significant reduction in venous thrombosis in hospitalized patients. 2 Mechanical methods, on the other hand, are not well studied, lack standardization and provide much weaker evidence of efficacy in reducing clinically significant thrombotic events. 2 Table 2. Risk Assessment of Hospitalized Patients 8 Patient Risk Groups (satisfaction of any one or more of the listed criteria) Adult Patients with Low Risk of VTE: No reduction in mobility compared to usual state Day surgery 1 and no risk factors for VTE (Table 2) Surgical procedure with a total anesthetic and surgical time of less than 60 minutes with no risk factors for VTE (Table 2) Adult Patients with Moderate or High Risk of VTE: Any medical or surgical patient having had or are expected to have significantly reduced mobility for 3 days or more Medical patients with ongoing reduced mobility (compared to their usual state) AND have one or more risk factors for VTE (Table 1) Surgical procedure with a total anesthetic and surgical time 60 minutes or longer Acute surgical admission with an inflammatory or intra-abdominal condition Surgical patients with one or more risk factors for VTE (Table 1) Pediatric Patients with an increased risk of VTE: Use of central venous catheters Congenital heart disease Renal disease L-asparaginase Immobility Multiple trauma Inherited thrombophilia Malignancy Obstetrical Patients with an increased risk of VTE: 8 Having one or more risk factors for VTE (Table 2) Pregnancy-related risk factor: Ovarian hyperstimulation Hyperemesis gravidarum Multiple pregnancy Preeclampsia Emergency caesarean section Thromboprophylaxis Recommended early ambulation LMWH (consider UFH in renal failure) 5 7 Consult Paediatrician or Haematologist 1 Consider LMWH (UFH in renal failure) Author(s): Fraser Health CDST#: NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy. April 23, 2012

4 Page 4 of 35 CLINICAL PRACTICE GUIDELINE: Venous Thromboembolism (VTE) Prevention Guideline: Thromboprophylaxis AUTHORIZATION: VP, Medicine Date Approved: May 17, 2012 Date Revised: 1. Day surgery includes patients admitted and discharged within 24 hours for an elective surgical or invasive procedure. 2. Anticoagulant thromboprophylaxis is the method of first choice in medical and surgical patients without contraindications. In medical patients, there is no evidence for using mechanical thromboprophylaxis. In surgical patients, there is weak evidence for using mechanical thromboprophylaxis alone and weaker evidence for combining anticoagulant and mechanical prophylaxis to improve efficacy. 3. Prophylaxis should continue during hospitalization. Extended duration for up to 30 days after surgery is recommended in those having hip replacement, hip fracture surgery, abdominal or pelvic surgery for cancer, and those with multiple risk factors. 4. LMWH and UFH should not be given in patients with heparin-induced thrombocytopenia (HIT). Consider consulting Hematology regarding use of alternative agents. 5. If egfr is 10 30ml/min and duration of prophylaxis exceeds 10 days, can consider using UFH 5000 units BID instead of LMWH. If egfr <10 ml/min or dialysis dependent, use UFH 5000 units BID. 6. If patient s BMI >40 kg/m 2, consider increasing dose of LMWH or UFH. 7. UFH 5000 units BID should be used if patient is awaiting urgent surgery and eligible for neuraxial blockade. Refer to Peri-operative Pain Service or Anesthesia regarding timing of epidural catheter insertion and removal. 8. Consult Ped Hematologist services at BCCH 7.1. Contraindications for Anticoagulant Thromboprophylaxis Pharmacological prophylaxis has the strongest evidence for preventing VTE; however, patients should not receive anticoagulant thromboprophylaxis if they have one or more of the following risk factors for bleeding: Table 3. Contraindications for Anticoagulant Prophylaxis 8 Active bleeding of clinical significance requiring intervention High risk of serious bleeding that might be life-threatening High risk of bleeding into a critical site (e.g., intracranial, intraspinal, pericardial, intraocular, retroperitoneal) Untreated major bleeding disorder Acquired systemic coagulopathy Platelet count less than 50 x 10 9 /L In these patients, mechanical thromboprophylaxis should be considered. However, pharmacological prophylaxis should be started when the contraindication resolves Contraindications for Mechanical Thromboprophylaxis As a group, mechanical thromboprophylaxis methods have important advantages and limitations. 1 Patients should not receive mechanical thromboprophylaxis if they have one or more of the following conditions: Table 4. Contraindications for Mechanical Thromboprophylaxis 8 Acute stroke with immobility (unable to walk independently to the toilet) Peripheral vascular disease with absent pedal pulses Severe peripheral neuropathy Skin breakdown, ulcers, gangrene, cellulitis, or dermatitis Skin grafting within last 3 months Allergy to stocking or compression cuff materials Unable to size or apply properly due to leg deformity, severe edema, recent surgery or trauma Author(s): Fraser Health CDST#: NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy. April 23, 2012

5 Page 5 of 35 CLINICAL PRACTICE GUIDELINE: Venous Thromboembolism (VTE) Prevention Guideline: Thromboprophylaxis AUTHORIZATION: VP, Medicine Date Approved: May 17, 2012 Date Revised: 8. DOCUMENTATION Pre-Printed Orders (PPO) Medication Administration Record (MAR) 9. EDUCATION On-line education module for VTE Patient/family pamphlets 10. EVALUATION / MONITORING Provincial Clinical Care Management (CCM) Requirement for VTE Prophylaxis Accreditation Canada Required Organizational Practice REFERENCES 1. Vancouver Coastal Venous Thromboembolism Prevention Guideline: Thromboprophylaxis (Nov 2010) (see Appendix for complete VCH VTE Guideline document) VTE Guideline from VCH.PDF 2. Geerts WH, Bergqvist D, Pineo GF et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133(6 Suppl):381S-453S. 3. Accreditation Canada, Required Organizational Practices, September Retrieved February 16, 2012 from 4. Safer Healthcare Now, Getting Started Kit, November Retrieved February 16, 2012 from it.pdf 5. Clinical Care Management retrieved March 15, 2012 from 6. Khan NA, Quan H, Bugar JM, Lemaire JB, Brant R, Ghali WA. Association of postoperative complications with hospital costs and length of stay in a tertiary care center. J Gen Intern Med 2006; 21(2): Sunnybrook Thromboprophylaxis Guidelines Nov Zhan C, Miller MR. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. JAMA 2003; 290(14): Author(s): Fraser Health CDST#: NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy. April 23, 2012

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