Venous Thromboembolism Prophylaxis

Approved by: Venous Thromboembolism Prophylaxis Vice President and Chief Medical Officer; and Vice President and Chief Operating Officer Corporate Policy & Procedures Manual Number: Date Approved January 6, 2015 Next Review (3 years from Effective Date) January 2018 Purpose Policy Statement Applicability To minimize the risk of venous thromboembolism to patients admitted to Covenant Health acute care facilities by requiring assessment for risk of venous thromboembolism. Patients admitted to Covenant Health acute care facilities shall be assessed for their risk of venous thromboembolism and receive optimal evidence based thromboprophylaxis. This policy and procedure applies in all Covenant Health acute care facilities, and all staff, members of the medical staff, volunteers, students and any other persons acting on behalf of Covenant Health. Responsibility The most responsible health practitioner is responsible to complete an assessment of risk of venous thromboembolism (VTE) and bleeding risk. During the course of treatment, all health care professionals shall demonstrate compliance with this policy on an ongoing basis by identifying patients who are at risk that are not receiving thromboprophylaxis or whose bleeding risk has subsided. This information is to be provided to the patient s health care team immediately. Principles Policy Elements Venous thromboembolism is one of the most common complications of hospitalization and the most common preventable cause of hospital death. 1. Assessment for Venous Thromboembolism Risk 1.1 Every adult (18 years of age and older) acute care hospitalized patient shall be assessed for venous thromboembolism risk at the time of admission to hospital, at the time of a significant change in clinical status, at the time of transfer from one type of care to another, and at discharge. 2. Commencement of Venous Thromboprophylaxis 2.1 Optimal, evidence-based thromboprophylaxis shall be provided to every adult acute care patient in whom it is indicated based on their risk of thrombosis, their risk of bleeding, and available options in the facility. Procedure Definitions Covenant Health health care professionals shall adhere to the Covenant Health Practice Support Document Guidelines for Venous Thromboembolism Prophylaxis (as adapted from Alberta Health Services). Deep vein thrombosis means a thrombus (blood clot) occurring in one or more deeper veins, especially in the legs, where it may produce leg swelling and/or pain. Health care professional means an individual who is a member of a regulated health discipline, as defined by the Health Disciplines Act or the Health Professions Act, and

2 of 12 who practices within scope or role. Most responsible health practitioner means the health practitioner who has responsibility and accountability for the specific treatment/procedure(s) provided to a patient and who is authorized by Covenant Health to perform the duties required to fulfill the delivery of such a treatment/procedure(s) within the scope of his/her practice. Patient means all persons who receive or have requested health care or services from Covenant Health and its health care providers. This term is inclusive of residents and clients Thromboprophylaxis means the use of mechanical methods or anticoagulant medication to prevent venous thromboembolism from developing in patients who are at risk. Venous thromboembolism (VTE) means a thromboembolic event (blood clot) that develops within the venous system and includes both deep vein thrombosis and pulmonary embolism. Related Documents Venous Thromboembolism Prophylaxis Practice Support Document Guideline (attached) References Alberta Health Services Venous Thromboembolism Prophylaxis Policy Level 1 Chronological Revision Date(s) N/A

3 of 12 PRACTICE SUPPORT DOCUMENT for VENOUS THROMBOEMBOLISM PROPHYLAXIS Objectives Applicability To outline the recommended approach to venous thromboembolism (VTE) prophylaxis for all adult patients admitted to a Covenant Health acute care facility. This policy and procedure applies in all Covenant Health acute care facilities, and all staff, members of the medical staff, volunteers, students and any other persons acting on behalf of Covenant Health. GUIDELINE: The underlying principle guiding the use of VTE is that all adult acute care patients at risk receive optimal evidence based venous thromboprophylaxis. An assessment of risk of VTE and bleeding risk should be made by the most responsible health practitioner at the time of admission to an acute care facility. All health care professionals should identify patients who are at risk that are not receiving thromboprophylaxis or whose bleeding risk has subsided. This information is to be provided to the patient s health care team immediately. The approach to thromboprophylaxis involves three steps: STEP 1 Is Thromboprophylaxis NOT INDICATED? 1.1 For patients who are at their normal levels of mobility and expected to have a length of stay less than 48 hours, thromboprophylaxis is generally not needed unless multiple other VTE risk factors are present. 1.2 If no specific thromboprophylaxis is provided, patients should be encouraged to be as mobile as possible. 1.3 If a patient s clinical status changes significantly, a decision about thromboprophylaxis should be reassessed at that time. 1.4 For patients who are identified as receiving end of life care, anticoagulant prophylaxis is not given. STEP 2 Is Anticoagulant Thromboprophylaxis CONTRAINDICATED? 2.1 Absolute contraindications to anticoagulant thromboprophylaxis are: a) active, clinically-important bleeding; b) platelets less than 50 x 10 9 /L and/or; c) major bleeding disorder.

4 of 12 2.2 Relative contraindications to anticoagulant thromboprophylaxis are: a) recent intracranial haemorrhage; b) recent perispinal bleeding and/or; c) recent high-risk bleeding surgery. 2.3 For patients who are actively bleeding or have a high risk of bleeding (see Table 1, High Bleeding Risk Considerations in Hospitalized Medical Patients, for more details), anticoagulant prophylaxis is not given. In this situation, bilateral, properly measured and fitted, calf-length graduated compression stockings (GCSs) or sequential compression devices (SCP) are placed. a) These patients should be reassessed daily for proper use of the stockings/compression device and bleeding risk. When the high bleeding risk decreases, anticoagulants should be started. - Table 1 - High Bleeding Risk Considerations in Hospitalized Medical Patients *Peptic ulcer disease Hepatic failure Age (greater than 75 years of age) *Prior bleeding history Rheumatic diseases Renal failure *Thrombocytopenia Active cancer Intensive Care Unit / Coronary Care Unit stay Decousus et al, Chest 2011:69 * Indicates high bleeding risk either as a single factor or associated with other risk factors. 2.4 For patients with heparin-induced thrombocytopenia (HIT), either currently or in the past, unfractionated heparin (UFH) or low molecular weight heparin (LMWH) is contraindicated. In this setting, the internal medicine or haematology service should be contacted for advice the most appropriate thromboprophylaxis in the setting of HIT is generally fondaparinux 2.5 milligrams (mg) subcutaneously (sc) once daily or intravenous argatroban. a) In order to avoid the higher risk of HIT, use of UFH should be minimized.

5 of 12 STEP 3 Provide Thromboprophylaxis 3.1 Assess risk of VTE based on known risk factors: a) See Table 2, Risk Factors for VTE. - Table 2 - Risk Factors for VTE Age greater than 60 years Inflammatory Bowel Disease (IBD) Obesity Active cancer Estrogen therapy Immobility Intubation Pregnancy and post partum Surgery Thrombophilia Trauma Myeloproliferative disorders Prior VTE Nephrotic syndrome Severe acute respiratory illness or Congestive Heart Failure (CHF) b) See Table 3, Levels of Thromboembolism Risk and Recommended Thromboprophylaxis in Hospital Patients

6 of 12 - Table 3 - Levels of Thromboembolism Risk and Recommended Thromboprophylaxis in Hospital Patients Level of VTE Risk Low Moderate High Very High High bleeding risk Risk Factors for VTE Minor surgery Mobile medical patient Age less than 60 years Most general, gynecology or urological surgery patients Immobilized medical patients Age greater than 75 years Additional risk factors for VTE Hip or knee arthroplasty Major trauma Hip fracture Spinal cord injury Approximate Deep Vein Thrombosis (DVT) Risk Without Prophylaxis Less than 10% 10 40% 40 60% 40 80% Suggested Thromboprophylaxis Options Early Ambulation LMWH LDUH bid or tid Fondaparinux LMWH LDUH tid Fondaparinux LMWH Fondaparinux Vitamin K Antagonist AntiXa inhibitors Mechanical prophylaxis with IPDs Fondaparinux (suggest consult to Internal Medicine or Haematology Service) 3.2 For most patients, the recommended thromboprophylaxis is low molecular weight heparin (LMWH) once daily. a) In general, for weight less than 40 kg, it is recommended that a dose reduction be considered. b) In general, for weight greater than 100 kg, it is recommended that a dose increase be considered. For weight greater than 120 kg, even higher doses should be considered. c) A dosage reduction is recommended for prophylactic doses of LMWH for patients with severe renal impairment (creatinine clearance less than 30 ml/min.) For patients with creatinine clearance less than 20 ml/min, low dose unfractionated heparin prophylaxis is preferred over LMWH.

7 of 12 d) For arthroplasty patients, the first dose of LMWH is generally given six hours post operatively and then daily. e) If patients are already receiving LMWH and are scheduled for an epidural insertion, it is recommended that the anticoagulant is held for 18 to 24 hours prior to insertion. f) For patients with epidural catheters, the LMWH dose is held to facilitate catheter removal in the morning and to allow for at least 18 hours after the previous LMWH dose before catheter removal. For patients who have had an epidural catheter removed, the next dose of LMWH should be delayed for at least two hours after removal.

8 of 12 APPENDIX A General Considerations: RECOMMENDED THROMBOPROPHYLAXIS THERAPY BY PATIENT GROUP 1. Although the recommended options apply to most patients in each group, individual patient factors may suggest an alternate approach. 2. For all patients in whom it is possible and appropriate, early and frequent mobilization and ambulation are essential. 3. In general, for weight less than 40 kg or creatinine clearance less than 30 ml/minute, it is suggested that the prophylactic LMWH dose be reduced to the next lower pre-filled syringe dose for enoxaparin only. In general, for weight greater than 100 kg, consider doubling the LMWH dose. At weights greater than 120 kg, even higher doses should be considered. 4. The duration of Thromboprophylaxis is not based on mobility status alone. Given evidence suggest low to moderate bleeding risk associated with use of prophylactic dosages of LMWH, in absence of clinically significant bleeding or in setting of procedures involving critical areas where achieving hemostasis is limited or potentially catastrophic bleeding is possible, in most instances, TP should not be withheld. [Bump, 2008] Legend for following chart: ER = emergency room GCS = graduated compression stockings TP = thromboprophylaxis SCD = sequential compression devices UFH = unfractionated heparin LMWH = low molecular weight heparin TJR = total joint replacement VTE = venous thromboembolism LDUH = low dose unfractionated heparin

9 of 12 Patient Group High bleeding risk Neuraxial blockage / spinal anaesthesia Heparin-induced thrombocytopenia (HIT) current or previous Recommended Thromboprophylaxis Options Properly fitted bilateral calf-length GCS or SCD used continuously (except for bathing or ambulating). UFH bid / tid Can use LMWH after epidural removed If LMWH has been given, hold LMWH for 18 to 24 hours prior to insertion or removal of neuraxial catheter Suggest haematology / internal medicine consult No heparin or LMWH Fondaparinux 2.5 mg SC once daily or argatroban Initiation ASAP after emergency admission. Just prior to surgery for elective surgical procedures. 2-4 hours after insertion of neuraxial catheter At least two hours after removal of neuraxial catheter As soon as the diagnosis of HIT considered. Burn unit patients LMWH q 24 hours or LDUH bid / tid When there is evidence of primary hemostasis Duration Until bleeding risk allows the use of anticoagulants. Discharge and platelet count greater than 120 x 10 9 /L Cardiovascular surgery LMWH q 24 hours or LDUH bid / tid Primary hemostasis Unit discharge Chronic kidney disease UFH bid / tid On admission Critical care General Surgery (major) Use Critical Care order sets In most cases, the prophylaxis is LMWH q 24 hours or LDUH bid / tid properly fitted bilateral calf-length GCS or SCD until anticoagulants can be started Use General Surgery order sets In most cases, the prophylaxis is LMWH q 24 hours or LDUH bid / tid properly fitted bilateral calf-length GCS First dosing time after admission, if possible See Critical Care order sets 0-1 hour pre-op (if no epidural) or 2-4 hours after insertion of epidural Include TP in transfer orders

10 of 12 Patient Group Recommended Thromboprophylaxis Options or SCD until LMWH can be started Initiation Duration Gynecology Use Gynecology order sets In most cases, the prophylaxis is LMWH q 24 hours or LDUH bid / tid properly fitted bilateral calf-length CGS or SCD until anticoagulants can be started First dosing time after ER admission or post-op; or the following morning if there are bleeding concerns Hip and knee arthroplasty Use Arthroplasty order sets In most cases, the prophylaxis is LMWH q 24 hours For patients with moderate renal dysfunction, use dose reduced LMWH SC q 24 hours or LDUH bid Or fondaparinux or rivaroxaban or Vitamin K antagonist Six hours post-op 15 days 28 days if higher risk and THR Hip fracture Use Hip Fracture order sets LMWH q 24 hours or fondaparinux or warfarin Dosage reduction if weight less than 40 kg or CrCl less than 30 ml/min If surgery is delayed, start LMWH on admission 28 35 days Internal medicine (and medical subspecialties) Use Medicine admission order sets / DVT prophylaxis order sets For most patients, LMWH q 24 hours; or LDUH bid / tid or fondaparinux Dosage adjustment for high or low weight and renal dysfunction properly fitted bilateral calf-length GCS/SCD until anticoagulant can be First dosing time after admission Consider extended for cancer, stroke

11 of 12 Patient Group Recommended Thromboprophylaxis Options Initiation Duration started Neurosurgery Three options: properly fitted bilateral calf-length GCS or SCD LMWH q 24 hours LDUH bid / tid Start with bilateral calf-length GCS/SCD and switch to LMWH when risk of bleeding decreases For GCS/SCD, start just prior to surgery for elective surgical procedures and ASAP after admission for major neurotrauma or non-traumatic intracranial hemorrhage For LMWH, no sooner than day after surgery Obstetrics LMWH q 24 hours Initial dose of UFH given immediately post caesarean for high risk individuals LMWH started at least 2 hours after epidural removed Extended for 6 weeks and/or converted to warfarin for those with prior VTE or with thrombophilia Oncology (medical and radiation) LMWH q 24 hours properly fitted bilateral calf-length GCS or SCD until LMWH can be started First dosing time after admission Consider benefits vs. risk of post-discharge TP Pediatrics Early mobilization except in very high risk population No clear evidence supporting TP in pediatric population Plastic Surgery LMWH q 24 hours, fondaparinux, LDUH bid / tid Pre-op or post-op 6-12 hours Spinal cord injury LMWH q 12 or 24 hours ASAP after admission (once hemostasis is evident) from rehab Spine surgery LMWH q 24 hours Evening or morning after surgery Stroke ischemic Use Stroke admission order sets First dosing time after admission

12 of 12 Patient Group Recommended Thromboprophylaxis Options For most patients, LMWH q 24 hours Dosage adjustment for low or high weight and renal dysfunction properly fitted bilateral calf-length GCS or SCD until LMWH can be started Initiation Duration Stroke hemorrhagic Use Stroke admission order sets Bilateral, properly fitted calf-length GCS or SCD After approx. 5-7 days, consider switch to LMWH as for ischemic stroke On admission Sub-Acute Care LMWH q 24 hours or LDUH bid For extended prophylaxis in spinal cord injury, stroke associated with paralysis, hip fracture or total joint and abdominal / pelvic cancer therapy Continuation of prophylaxis at transitions 10 35 days Trauma properly fitted bilateral calf-length GCS/SCD until LMWH can be started Usual risk patients: LMWH q 24 hours High risk patients (lower extremity fracture): LMWH q 12 hours ASAP after admission (once hemostasis is evident) from rehab Urology Use Urology order sets In most cases the prophylaxis is LMWH q 24 hours or LDUH bid properly fitted bilateral calf-length GCS/SCD until LMWH can be started Options: First dosing time after surgery Morning after surgery if there are bleeding concerns First dosing time after ER admission or post-op