A new guideline was published this week about venous thromboembolism (VTE) prophylaxis in hospitalized medical sick patients and in stroke patients [link here; ref 1].
The key points of this guideline, which is based on a systematic evidence review from the published medical literature, are that
- not EVERY hospitalized (non-surgical) patient should automatically get VTE prophylaxis;
- a risk-benefit assessment (risk of VTE versus risk of bleeding) should take place for every patient before prescribing VTE prophylaxis;
- compression stockings (“TED hose” and others) should NOT be used;
- hospital performance measures need to be carefully worded and constructed to avoid that pharmacologic prophylaxis is inappropriately given to patients at low risk for VTE and physicians pushed into giving universal VTE prophylaxis to EVERY hospitalized patient.
The systematic review furthermore highlights that (a) anticoagulant VTE prophylaxis does increase the risk for bleeding, (b) compression stockings are not effective in VTE prevention and increase the risk for skin damage, and (c) efficacy and safety of intermittent pneumatic compression devices as a stand-alone intervention have not been appropriately studied. The guideline does NOT deal with surgical patients.
Clinical Relevance of this Guideline
This newly published guideline is of relatively little direct relevance for the practicing physician, unless he/she is involved in hospital-wide VTE prevention activities/policies. It does NOT provide guidance as to whom to prophylax and whom not.
Health Policy Relevance of this Guideline
This guideline is more of importance for those involved in hospital-wide VTE prevention policies/strategies. It states that VTE prevention guidelines at an institution should NOT promote that EVERY hospitalized medically sick or stroke patient should get VTE prophylaxis, but that an individual risk assessment of VTE risk and bleeding risk should determine who gets prophylaxis and who not.
Other Important Documents (The Surgeon General, AHRQ)
It seems worthwhile at this point to re-mention 2 existing resources:
- The Surgeon General’s 2008 landmark “Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism” [link here; ref 2] very nicely summarizes in its Section IV, page 26-32, the key activities needed to decrease morbidity and mortality from DVT and PE. Each of three main groups – (i) communities, (ii) the health care system, and (iii) policy makers and government – is provided with a clear mission, suggested actions, and suggestions for evaluation of progress made. This is a great resource and provides a clear marching plan.
- The Agency for Healthcare Research and Quality (AHRQ) published a helpful, practical VTE prevention implementation paper in 2008, “Preventing Hospital- Acquired Venous Thromboembolism – A Guide for Effective Quality Improvement” [link here; ref 3].
- Qaseem A et al. Venous thromboembolism prophylaxis in hospitalized patients: A clinical practice guideline from the American College of Physicians. Ann Intern Med 2011;155:625-632 (link here)
- The U.S. Surgeon General. “Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism” http://www.surgeongeneral.gov/topics/deepvein. 2008.
- Agency for Healthcare Research and Quality (AHRQ). “Preventing Hospital-Acquired Venous Thromboembolism. A Guide for Effective Quality Improvement”. http://www.ahrq.gov/qual/vtguide/index.html#contents. August 2008.
For Patients: A summary of the guideline, written for patients, can be found here.
Disclosure: I have no financial conflict of interest relevant to this post.
Last updated: Nov 4th, 2011
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