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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 11  |  Issue : 2  |  Page : 64-67

How to manage venous thromboembolism risk in hospitalized medical patients


Department of Medicine, King Abdulaziz Medical City; King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

Date of Submission19-Dec-2019
Date of Decision15-Jan-2020
Date of Acceptance16-Mar-2020
Date of Web Publication28-Jul-2020

Correspondence Address:
Dr. Ali Abduljabbar Alaklabi
Almorooj Quarter, Alanbaryon Street, Buliding #3317, P.O. Box 12281, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joah.joah_88_19

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  Abstract 

BACKGROUND: Deep venous thrombosis causes morbidity and mortality for hospitalized patients. There are several risk factors for developing deep venous thrombosis including trauma, immobilization, and surgery. Complications of deep venous thrombosis result from the delay in diagnosis and treatment, so prophylaxis is the perfect option to avoid these serious complications, especially for those at risk.
AIM: The aim of this is to investigate the impact of DVT protocol on thromboprophylaxis in minimizing the disease burden of under-recognized and preventable pathology.
MATERIALS AND METHODS: This is a retrospective descriptive study which used DVT protocol through the Knowledge Translation Committee (KTC).
RESULTS: Suboptimal prophylaxis decreased from 47% in 2011 to 6% in 2017, whereas appropriate prophylaxis increased among patients from 45% in 2011 to 89% in 2017.
CONCLUSION: There was an increase in offering DVT prophylaxis for hospitalized medical patients as a result of the implementation of DVT protocol through KTC.

Keywords: DVT, DVT prophylaxis, Kingdom of Saudi Arabia, Knowledge Translation Committee


How to cite this article:
Alaklabi AA, Alqahtani S. How to manage venous thromboembolism risk in hospitalized medical patients. J Appl Hematol 2020;11:64-7

How to cite this URL:
Alaklabi AA, Alqahtani S. How to manage venous thromboembolism risk in hospitalized medical patients. J Appl Hematol [serial online] 2020 [cited 2020 Sep 26];11:64-7. Available from: http://www.jahjournal.org/text.asp?2020/11/2/64/290969




  Introduction Top


Venous thromboembolism (VTE) is a cardiovascular disorder that is in the third rank regarding prevalence.[1] VTE prevalence ranges from 10% to 33% among hospitalized patients, VTE including both deep venous thrombosis (DVT) and pulmonary embolism (PE).[2] Deep venous thrombosis (DVT) is one of the major causes of mortality and morbidity among hospitalized patients; however, it can be prevented.[3],[4] DVT has been increased among hospitalized patients,[5] and it was stated that 450,000 hospitalized patients and 50,000 individuals die every year in the USA associated with DVT.[6] There are several risk factors for developing DVT including older age, trauma, cancer, immobilization, surgery, and antiphospholipid syndrome.[7],[8] A study from Saudi Arabia[9] showed that patients diagnosed with DVT were with a mean age of 44.16 years. Symptoms of DVT include swelling, pain, and discoloration.[10] However, patients with acute lower extremity DVT often do not show warmth, erythema, pain, swelling, or tenderness.[11] Daly in the diagnosis of DVT may return to the nonspecific nature of the clinical presentation of DVT and hence delay in therapy initiation, and this may lead to morbidity and mortality.[9] Complications of DVT range from postthrombotic syndrome which involves organic changes of the tissues and veins in the leg to PE with a mortality rate of 15% within 3 months.[10],[12] Treatment strategies of DVT and PE have been changes through the past 2 decades and will continue to change in the coming years.[9] The American College of Chest Physicians guidelines on antithrombotic therapy recommended using anticoagulant prophylaxis as Grade 1A for at-risk medical patients in order to prevent DVT;[4] however, DVT prophylaxis is underutilization as there are only 16%–33% of medial patients at DVT risk who received prophylaxis.[13],[14] Hence, in the current study, we aimed to investigate the influence of DVT protocol through the Knowledge Translation Committee (KTC) in King Abdulaziz Medical City (KAMC).


  Materials and Methods Top


This is a retrospective descriptive study which included 1073 patients who enrolled in 6 medical wards at KAMC using deep vein thrombosis (DVT) protocol through KTC between 2011 and 2017 which involves:

  • Daily checking of the total patents on DVT prophylaxis dose, through patients' medical records in the best care system
  • Scoring patients who are eligible for prophylactic therapy but not receiving the dose, based on DVT prophylaxis guidelines
  • Contact the treating physicians to remind them to start giving the patient the recommended dose.


Statistical analysis

Data obtained were summarized as percentage according to year and prophylaxis status.


  Results Top


The current study included 1073 patients in 6 medical wards at KMAC during 7 years, starting from 2011 and ending in 2017. During 2011, prophylaxis was not indicated for 2% of patients, 6% of patients were eligible but did not have prophylaxis, 45% received appropriate prophylaxis, and 47% get suboptimal prophylaxis [Table 1]. During 2012, 10% were eligible but did not receive prophylaxis, 73% received appropriate prophylaxis, 17% received suboptimal prophylaxis, and 2% did not receive prophylaxis at all [Table 1]. In 2013, there were 6% eligible for prophylaxis but did not receive it, 79% and 15% received appropriate and suboptimal prophylaxis, respectively, while 4% had no prophylaxis [Table 1]. During 2014, only 2% of patients were not indicated to receive prophylaxis, 5% did not receive prophylaxis although they were eligible, 82% and 13% received appropriate and suboptimal prophylaxis, respectively, and 5% received no prophylaxis [Table 2]. In 2015, the percentage of those who were not indicated to receive prophylaxis increased to 7% and the same percentage was found to be eligible but did not receive prophylaxis, whereas 86%, 8%, and 6% received appropriate, suboptimal, and no prophylaxis, respectively [Table 2]. In 2016, prophylaxis was not indicated for 3%, prophylaxis was not presented although patients were eligible for 6%, and 86%, 7%, and 7% received appropriate, suboptimal, and no prophylaxis, respectively [Table 2]. During 2017, 4% did not receive prophylaxis, 3% were not indicated to receive it, and 5%, 89%, and 6% were eligible but did not receive it, received appropriate prophylaxis, and received suboptimal prophylaxis, respectively [Table 2]. Prophylaxis during 2011–2017 is shown in [Figure 1]. There was an increase in receiving appropriate prophylaxis among patients [Figure 2], the appropriate prophylaxis increased from 45% to 89% during 2011–2017, while the suboptimal prophylaxis decreased from 47% in 2011 to 6% in 2017.
Table 1: Prophylaxis during 2011.2013

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Table 2: Prophylaxis during 2014.2017

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Figure 1: DVT statistics 2011–2017

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Figure 2: The percentage of patients received suboptimal and appropriate prophylaxis through 2011–2017

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  Discussion Top


In the current study, DVT prophylaxis was investigated for patients at KAMC through 2011–2017. In 2011, it was found that suboptimal prophylaxis received was more than appropriate prophylaxis (47% vs. 45%, respectively) and only 6% were eligible for prophylaxis and received it. In agreement with our findings, a Saudi study published in 2011 reported that only small number of patients eligible to VTE prophylaxis received it.[15] Other studies[13],[14] showed that DVT prophylaxis was admitted to 16%–33% of medical patients at risk. The reason for the low presentation of prophylaxis for medical patients comparing to surgical patients is unknown.[16],[17],[18] The use of DVT protocol KTC resulted in many advantages regarding prophylaxis. By analysis, it was found that the trend of patients eligible to prophylaxis but it was decreased through the past 4 years (2014–2017) than in 2011–2013. Furthermore, suboptimal prophylaxis decreased over the years from 47% in 2011 to 6% in 2017 with an increase in affording appropriate prophylaxis from 45% in 2011 to 89% in 2017. This increase in presentation of appropriate prophylaxis and decrease in suboptimal prophylaxis show the effectiveness of DVT protocol and hence prevention of DVT and its associated mortalities and morbidities, especially because DVT was reported to be highly prevalent in some areas of Saudi Arabia. One study from Jeddah showed that DVT was highly prevalent in Jeddah and knowing risk factors was mandatory to predict patients who will develop it and then protect them.[19] Another study showed that proximal DVT was prevalent in 2%–4.9% of hospitalized medical patients.[20] In one meta-analysis,[10] it was found that anticoagulant prophylaxis for DVT in hospitalized medical patients reduced symptomatic DVT, but this reduction was insignificant. It was reported in a systemic review that anticoagulant prophylaxis resulted in reduction by 49% and 55% in the risk of proximal or distal asymptomatic DVT and in the risk for asymptomatic proximal DVT in hospitalized medical patients.[21] There is a lack in studies investigating the impact of prophylaxis on the prevalence of DVT as well as the influence of guideline and prophylaxis protocol application, so we could not find more results to compare with ours. There is another limitation in our study that we could not reach the type of prophylaxis applied to the hospitalized patients. Further studies are very recommended.


  Conclusion Top


The implementation of DVT protocol through KTC resulted in increasing DVT appropriate prophylaxis and a decrease in suboptimal prophylaxis; hence, KTC improved the use of DVT prophylaxis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Amin A, Stemkowski S, Lin J, Yang G. Thromboprophylaxis rates in US medical centers: Success or failure? J Thromb Haemost 2007;5:1610-6.  Back to cited text no. 1
    
2.
Kanaan AO, Silva MA, Donovan JL, Roy T, Al-Homsi AS. Meta-analysis of venous thromboembolism prophylaxis in medically Ill patients. Clin Ther 2007;29:2395-405.  Back to cited text no. 2
    
3.
Okuhara A, Navarro TP, Procópio RJ, Bernardes Rde C, Oliveira Lde C, Nishiyama MP. Incidence of deep vein thrombosis and quality of venous thromboembolism prophylaxis. Rev Col Bras Cir 2014;41:2-6.  Back to cited text no. 3
    
4.
Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, et al. Prevention of venous thromboembolism: American college of chest physicians evidence-based clinical practice guidelines (8th Edition). Chest 2008;133:381S-453S.  Back to cited text no. 4
    
5.
Stein PD, Beemath A, Olson RE. Trends in the incidence of pulmonary embolism and deep venous thrombosis in hospitalized patients. Am J Cardiol 2005;95:1525-6.  Back to cited text no. 5
    
6.
Cook D, McMullin J, Hodder R, Heule M, Pinilla J, Dodek P, et al. Prevention and diagnosis of venous thromboembolism in critically ill patients: A Canadian survey. Crit Care 2001;5:336-42.  Back to cited text no. 6
    
7.
What are the Signs and Symptoms of Deep vein Thrombosis? National Heart, Lung, and Blood Institute; 2011.  Back to cited text no. 7
    
8.
Severinsen MT, Johnsen SP, Tjønneland A, Overvad K, Dethlefsen C, Kristensen SR. Body height and sex-related differences in incidence of venous thromboembolism: A Danish follow-up study. Eur J Intern Med 2010;21:268-72.  Back to cited text no. 8
    
9.
Ahmed MM, Akbar DH, Al-Shaikh AR. Deep vein thrombosis at King Abdul Aziz University Hospital. Saudi Med J 2000;21:762-4.  Back to cited text no. 9
    
10.
Endig H, Michalski F, Beyer-Westendorf J. Deep vein thrombosis–current management strategies. Clinical medicine insight. Therapeutics 2016;8:CMT-S18890.  Back to cited text no. 10
    
11.
Lectere Jr., Illescas F, Jarzen P. Diagnosis of DVT. In: Lectere Jr., editor. Venous Thrombo Embolic Disorders. Philladelphia, USA: Lea and Febiger; 1991. p. 176-228.  Back to cited text no. 11
    
12.
Piazza G, Seddighzadeh A, Goldhaber SZ. Double trouble for 2,609 hospitalized medical patients who developed deep vein thrombosis: Prophylaxis omitted more often and pulmonary embolism more frequent. Chest 2007;132:554-61.  Back to cited text no. 12
    
13.
Goldhaber SZ, Dunn K, MacDougall RC. New onset of venous thromboembolism among hospitalized patients at Brigham and Women's Hospital is caused more often by prophylaxis failure than by withholding treatment. Chest 2000;118:1680-4.  Back to cited text no. 13
    
14.
Kahn SR, Panju A, Geerts W, Pineo GF, Desjardins L, Turpie AG, et al. Multicenter evaluation of the use of venous thromboembolism prophylaxis in acutely ill medical patients in Canada. Thromb Res 2007;119:145-55.  Back to cited text no. 14
    
15.
Rehmani RS, Memon JI, Alaithan A, Ghabashi A, Shahid K, Latif S, et al. Venous thromboembolism risk and prophylaxis in a Saudi hospital. Saudi Med J 2011;32:1149-54.  Back to cited text no. 15
    
16.
Stratton MA, Anderson FA, Bussey HI, Caprini J, Comerota A, Haines ST, et al. Prevention of venous thromboembolism: Adherence to the 1995 American college of chest physicians consensus guidelines for surgical patients. Arch Intern Med 2000;160:334-40.  Back to cited text no. 16
    
17.
Caprini JA, Arcelus J, Sehgal LR, Cohen EB, Reyna JJ. The use of low molecular weight heparins for the prevention of postoperative venous thromboembolism in general surgery. A survey of practice in the United States. Int Angiol 2002;21:78-85.  Back to cited text no. 17
    
18.
Mesko JW, Brand RA, Iorio R, Gradisar I, Heekin R, Leighton R, et al. Venous thromboembolic disease management patterns in total hip arthroplasty and total knee arthroplasty patients: A survey of the AAHKS membership. J Arthroplasty 2001;16:679-88.  Back to cited text no. 18
    
19.
Alanazi RM, Alanazi AA, Alenezi IQ, Alsulobi AM, Almutairy AF, Ali WM, et al. Deep venous thrombosis in elderly patients as a surgical emergency at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. Electron Physician 2017;9:5754-9.  Back to cited text no. 19
    
20.
Francis CW. Prophylaxis for thromboembolism in hospitalized medical patients. N Engl J Med 2007;356:1438-44.  Back to cited text no. 20
    
21.
Lloyd NS, Douketis JD, Moinuddin I, Lim W, Crowther MA. Anticoagulant prophylaxis to prevent asymptomatic deep vein thrombosis in hospitalized medical patients: A systematic review and meta-analysis. J Thromb Haemost 2008;6:405-14.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

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