Guideline for the Prevention of Venous Thromboembolism ...

Guideline for the Prevention of Venous Thromboembolism (VTE) in Adult Hospitalised Patients

December 2018

Medication Services Queensland

Guideline for the prevention of Venous Thromboembolism (VTE) in adult hospitalised patients.

Published by the State of Queensland (Queensland Health), December 2018

This document is licensed under a Creative Commons Attribution 3.0 Australia licence. To view a copy of this licence, visit licenses/by/3.0/au ? State of Queensland (Queensland Health) 2018 You are free to copy, communicate and adapt the work, as long as you attribute the State of Queensland (Queensland Health). For more information contact: Medication Safety ? Medication Services Queensland, Department of Health, GPO Box 48, Brisbane QLD 4001, email Medication.Safety@health..au , phone (07) 3708 5306. An electronic version of this document is available at Disclaimer: The content presented in this publication is distributed by the Queensland Government as an information source only. The State of Queensland makes no statements, representations or warranties about the accuracy, completeness or reliability of any information contained in this publication. The State of Queensland disclaims all responsibility and all liability (including without limitation for liability in negligence) for all expenses, losses, damages and costs you might incur as a result of the information being inaccurate or incomplete in any way, and for any reason reliance was placed on such information.

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Contents

Contents .....................................................................................................................................3 Tables.........................................................................................................................................5 Introduction ................................................................................................................................6 Purpose ......................................................................................................................................6 Scope .........................................................................................................................................6 Related documents ....................................................................................................................7 Key definitions and abbreviations..............................................................................................8 Guideline overview...................................................................................................................10 General recommendations for VTE prevention in all stages of care ......................................11 1. Steps involved in VTE prevention ....................................................................................11

1.1 Assess all patients to identify need for VTE risk assessment ..................................11 1.2 Conduct advance-planning for planned hospitalisation patients..............................12 1.3 Undertake VTE risk assessment...............................................................................12

1.3.1 VTE risk assessment .........................................................................................12 1.3.2 VTE risk factors..................................................................................................13 1.3.3 Patients on therapeutic anticoagulation ............................................................14 1.3.4 Specific patient groups at increased VTE risk...................................................14 1.4 Assess contraindications to prophylaxis ...................................................................14 1.4.1 Contraindications to mechanical VTE prophylaxis ............................................15 1.4.2 Contraindications to pharmacological VTE prophylaxis....................................15 1.4.3 Special considerations with pharmacological VTE prophylaxis ........................16 1.5 Conduct baseline tests for heparin-based VTE prophylaxis ....................................16 1.5.1 Renal function estimation ..................................................................................17 1.6 Develop VTE Prevention Plan and initiate VTE prophylaxis ....................................17 1.7 Pharmacological Prophylaxis....................................................................................18 1.7.1 Options for pharmacological VTE prophylaxis ..................................................18 1.7.2 Standard dosing and timing ...............................................................................19 1.7.3 Neuraxial puncture or catheter insertion and removal ......................................20 1.7.4 Surgical patients on therapeutic anticoagulation...............................................21 1.7.5 Dose adjustment for prophylaxis in specific patients ........................................22 1.8 Mechanical prophylaxis.............................................................................................23 1.8.1 Types of mechanical prophylaxis ......................................................................23 1.8.2 Timing of imitation and duration of mechanical prophylaxis .............................24 1.8.3 Factors to consider on initiation of mechanical prophylaxis..............................24 1.9 Inferior Vena Cava (IVC) filters .................................................................................24 1.10 Monitor, reassess and update VTE prevention plan ................................................25 1.10.1 General VTE prophylaxis monitoring.................................................................25 1.10.2 Pharmacological VTE prophylaxis monitoring...................................................25 1.10.3 Mechanical VTE prophylaxis monitoring ...........................................................26 1.10.4 Reassess for risks of VTE and bleeding ...........................................................26 1.10.5 Update VTE prevention plan..............................................................................26 1.10.6 Write discharge plan and ensure transfer of care .............................................27 2 VTE prophylaxis guideline for individual patient cohorts .................................................28 2.1 Medical and Mental Health Patients .........................................................................28 2.1.1 Acute Stroke.......................................................................................................29

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2.1.2 Critically ill patients ............................................................................................30 2.1.3 Medical cancer inpatients ..................................................................................31 2.1.4 Acutely ill medical patients.................................................................................32 2.1.5 Mental health patients........................................................................................33 2.2 Surgical and orthopaedic patients ............................................................................34 2.2.1 General and abdominal-pelvic surgery..............................................................35 2.2.2 Major abdominal-pelvic surgery for cancer .......................................................36 2.2.3 Total hip arthroplasty and Total knee arthroplasty ............................................37 2.2.4 Fragility fractures of the pelvis, hip and proximal femur....................................38 2.2.5 Ambulatory patients with isolated lower limb immobilisation ............................39 2.2.6 Other orthopaedic procedures ...........................................................................40 2.2.7 Major trauma ......................................................................................................41 2.2.8 Craniotomy.........................................................................................................42 2.2.9 Cardiac surgery..................................................................................................43 2.2.10 Vascular surgery ................................................................................................44 2.2.11 Thoracic surgery ................................................................................................45 2.2.12 Elective spinal surgery .......................................................................................46 2.2.13 Bariatric surgery .................................................................................................47 Appendices ..............................................................................................................................48 Appendix 1: Patient and/or carer engagement ....................................................................48 Patient-centred care and shared decision making...........................................................48 General VTE information and education..........................................................................48 Ensure appropriate documentation..................................................................................48 Appendix 2: Advance-planning for planned hospitalisation patients...................................49 Patients on estrogen-containing medication....................................................................49 Patients on other medications that increase the risk of VTE...........................................49 Anaesthesia and VTE risk ................................................................................................49 Patients already receiving anticoagulation.......................................................................49 Patients on regular antiplatelet agents.............................................................................50 Appendix 3: Padua VTE Risk Assessment Model...............................................................51 Appendix 4: Caprini VTE Risk Assessment Model..............................................................52 References ...............................................................................................................................54 Review......................................................................................................................................57 Business Area Contact ............................................................................................................57 Approval and Implementation..................................................................................................57

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Tables

Table 1: Risk assessment models used by the statewide VTE Risk Assessment Tool.........13 Table 2: Pharmacological VTE prophylaxis options................................................................18 Table 3: LAM restrictions relating to pharmacological VTE prophylaxis options....................18 Table 4: Standard prophylactic doses in medical patients......................................................19 Table 5: Standard prophylactic doses and timing of prophylaxis in surgical patients ............19 Table 6: Standard prophylactic doses and timing of DOAC for THR/TKR surgery ................20 Table 7: Timing of anticoagulants and neuraxial puncture or catheter insertion/removal......21 Table 8: Heparin-based VTE prophylaxis dose adjustments for patients with renal impairment ...............................................................................................................................22 Table 9: DOAC VTE prophylaxis dose adjustments for THR/TKR patients with renal impairment ...............................................................................................................................22 Table 10: Recommendations for dose adjustment of LMWH in patients that are obese .......23 Table 11: VTE prophylaxis in acute stroke medical patients ..................................................29 Table 12: VTE prophylaxis in critically ill medical patients......................................................30 Table 13: VTE prophylaxis in medical cancer inpatients ........................................................31 Table 14: VTE prophylaxis in acutely ill medical patients .......................................................32 Table 15: VTE prophylaxis in mental health patients..............................................................33 Table 16: VTE prophylaxis in general and abdominal-pelvic surgery (non-cancer) patients .35 Table 17: VTE prophylaxis in major abdominal-pelvic surgery for cancer patients................36 Table 18: VTE prophylaxis in total hip arthroplasty and total knee arthroplasty ....................37 Table 19: VTE prophylaxis in fragility fractures of the pelvis, hip and proximal femur ...........38 Table 20: VTE prophylaxis in ambulatory patients with isolated lower limb immobilisation...39 Table 21: VTE prophylaxis in other orthopaedic procedures..................................................40 Table 22: VTE prophylaxis in major trauma surgical patients.................................................41 Table 23: VTE prophylaxis in craniotomy................................................................................42 Table 24: VTE prophylaxis in cardiac surgery.........................................................................43 Table 25: VTE prophylaxis in vascular surgery.......................................................................44 Table 26: VTE prophylaxis in thoracic surgery........................................................................45 Table 27: VTE prophylaxis in elective spinal surgery .............................................................46 Table 28: VTE prophylaxis in bariatric surgery .......................................................................47

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Introduction

Venous thromboembolism (VTE), a disease which encompasses deep vein thrombosis (DVT) and pulmonary embolism (PE) is a major health-care problem, resulting in significant mortality and morbidity, and expenditure in healthcare resources. PE remains one of the leading causes of preventable in-hospital deaths.(1) The prevention of VTE, or VTE prophylaxis, is an important patient safety strategy in hospital settings where patients are at risk of developing VTE.(2)

Purpose

This guideline provides recommendations regarding best practice for the prevention of VTE in adults admitted to Queensland Health facilities and those discharged from the emergency departments of Queensland public hospitals. The use of this guideline is not mandatory. The objectives of this guideline are to:

? provide guidance to clinicians on the prevention of VTE, ? minimise the incidence of VTE in patients admitted to hospital or discharged from the

emergency department, and ? optimise VTE prophylaxis to reduce adverse patient outcomes.

Scope

This guideline provides information for all Queensland Health employees (permanent, temporary and casual) and all organisations and individuals acting as its agents (including Visiting Medical Officers and other partners, contractors, consultants and volunteers).

This guideline is for use in adults (patients aged 18 years and over) admitted to hospital as well as the following groups:

? Day surgery or procedure patients that are undergoing day procedures under general and prolonged anaesthesia with significant reduction in their mobility

? Sub-acute facilities such as rehabilitation and palliative care

? Patients admitted to mental health (psychiatric) inpatient units

? Adult ambulatory patients with isolated injury and subsequent temporary lower limb immobilisation (including those that are discharged from Emergency Departments)

The following are outside the scope of this guideline:

? Pregnant and post-partum women (refer to `Queensland Clinical Guidelines: Venous thromboembolism (VTE) prophylaxis in pregnancy and the puerperium')

? Paediatric patients ? Outpatients including ambulatory cancer patients receiving chemotherapy as day

procedures ? Treatment of VTE

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Related documents

The general recommendations in this guideline have been developed utilising the following documents. Specific recommendations have also been individually referenced within the guideline.

Policies/Standards

? Queensland Health List of Approved Medicines ? National Safety and Quality Health Service Standard 4: Medication Safety ? Australian Commission on Safety and Quality in Health Care (ACSQHC) Venous

Thromboembolism Prevention Clinical Care Standard

Local procedures, guidelines and protocols

? Guideline for Anticoagulation and Prophylaxis Using Low Molecular Weight Heparin (LMWH) in Adult Inpatients (Queensland Health)

? Guidelines for Anticoagulation using Warfarin ? Adult (Queensland Health) ? Managing patients on dabigatran (Pradaxa?) (Queensland Health) ? Guideline for managing patients on a factor Xa inhibitor ? Apixaban (Eliquis?) or

Rivaroxaban (Xarelto?) (Queensland Health) ? Management of Adult Acute Heparin Induced Thrombocytopenia/Thrombosis (HIT)

(Queensland Health)

Supporting documents

? National Inpatient Medication Chart (NIMC)

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Key definitions and abbreviations

ACCP ACSQHC ADR Anticoagulated

Antiplatelet agent

APTT ARTG ASA

AUSCARE / AUSLAB BMI BSA Caprini risk assessment / Caprini score

CKD-EPI Charlson Index

CrCl DOAC

DVT eGFR EMM ESA GCS GEMNet Heparin-based VTE prophylaxis HIT/HITT ieMR INR IPC IVC filter

American College of Chest Physicians Australian Commission on Safety and Quality in Health Care Adverse Drug Reaction Receiving an anticoagulant (i.e. unfractionated heparin, low molecular weight heparin [dalteparin, enoxaparin, nadroparin], warfarin with INR in therapeutic range, direct oral anticoagulant [apixaban, dabigatran, rivaroxaban], danaparoid, bivalirudin, fondaparinux) Medication that inhibits platelet aggregation. As at publication antiplatelet agents available in Australia include: aspirin, dipyridamole, clopidogrel, prasugrel, ticagrelor, ticlopidine, abciximab, eptifibatide and tirofiban. Activated Partial Thromboplastin Time Australian Register of Therapeutic Goods Arthroplasty Society of Australia: a subspecialty group of the Australian Orthopaedic Association Online pathology results system / Pathology information technology system ? used in Queensland Health Body Mass Index Body Surface Area VTE risk assessment model commonly used in surgical patients. This is a `Point-Based Individualised' method of stratifying surgical patients into 4 different levels of VTE risk (very low, low, moderate or high). The Caprini score is calculated by adding the scores of all the factors present for an individual patient with the total score determining the VTE risk level. The Caprini model is used in this guideline for general and abdominal-pelvic surgery and thoracic surgery patients. Chronic Kidney Disease Epidemiology Collaboration A weighted index measure of comorbidity used to predict 1-year or 10-year mortality.(3) A calculator version is available at .

Creatinine Clearance Direct-acting oral anticoagulant [also referred to as non-vitamin K antagonist oral anticoagulant (NOAC)]. As at publication DOACs available in Australia include: direct thrombin inhibitor (dabigatran); and factor Xa inhibitors (apixaban, rivaroxaban) Deep Vein Thrombosis Estimated Glomerular Filtration Rate Electronic Medication Management European Society of Anaesthesiology Graduated Compression Stockings Guidelines in Emergency Medicine Network, United Kingdom Prophylactic dose of low molecular weight heparin or unfractionated heparin Heparin-Induced Thrombocytopenia / Thrombosis Integrated Electronic Medical Record International Normalised Ratio Intermittent Pneumatic Compression Inferior Vena Cava Filter

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