Thrombosis prophylaxis in surgical patients using the Caprini Risk Score

Do Decision Support Tools Decrease the Prevalence of Hospital-Acquired Venous Thromboembolisms When Compared to Clinical Judgement? A Single-Center Pre-Post Study

Introduction: Hospital-acquired venous thromboembolisms (HA-VTEs) carry a significant health burden on patients and a financial burden on hospitals due to reimbursement penalties. VTE prophylaxis at our institute was performed through utilizing an order set based on healthcare professionals' perceived level of risk. However, the use of standardized risk assessment models is recommended by multiple professional societies. Furthermore, integrating decision support tools (DST) based on the standardized risk assessment models has been shown to increase the administration of appropriate deep vein thrombosis (DVT) prophylaxis. Nonetheless, such scoring systems are not inherently flawless and their integration into EMR as a mandatory step can come at the risk of healthcare professional fatigue and burnout. We conducted a study to evaluate the incidence of HA-VTE and length of stay pre- and post implementation of a DST. Methods: We conducted a retrospective, pre-post-implementation observational study at a tertiary medical center after implementing a mandatory DST. The DST used Padua scores for medical patients and Caprini scores for surgical patients. Patients were identified through ICD-10 codes and outcomes were collected from electronic charts. Healthcare professionals were surveyed through an anonymous survey and stored securely. Statistical analysis was conducted by using R (version 3.4.3). Results: A total of 343 patients developed HA-VTE during the study period. Of these, 170 patients developed HA-VTE in the 9 months following the implementation of the DST, while 173 patients were identified in the 9 months preceding the implementation. There was no statistically significant difference in mean HA-VTE/1000 discharge/month pre- and post implementation (4.4 (SD 1.6) compared to 4.6 (SD 1.2), confidence interval [CI] -1.6 to 1.2, p = 0.8). The DST was used in 73% of all HA-VTE cases over the first 6 months of implementation. The hospital length of stay (LOS) was 14.2 (SD 1.9) days prior to implementation and 14.1 (SD 1.6) days afterwards. No statistically significant change in readmission rates was noted (8.8% (SD 2.6) prior to implementation and 15.53% (SD 9.6) afterwards, CI -14.27 to 0.74, p = 0.07). Of the 56 healthcare professionals who answered the survey, 84% (n = 47) reported to be dissatisfied or extremely dissatisfied with the DST, while 91% (n = 51) reported that it slowed them down. Conclusions: There were no apparent changes in the prevalence of HA-VTE, length of stay, or readmission rates when VTE prophylaxis was mandated through DST compared to a prior model which used order sets based on perceived risk. Further studies are needed to further evaluate the current risk assessment models and improve healthcare professionals' satisfaction with DST.

Sustained success of a Caprini postoperative venous thromboembolism prevention protocol over one decade

BACKGROUND

The objective of this study was to review the long-term efficacy of a post-operative venous thromboembolism (VTE) prevention program at our institution.

METHODS

We performed a review of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data at our hospital from January 2008-December 2022. The primary outcome was risk-adjusted VTE events.

RESULTS

In 2009, a postoperative general surgery patient was three times more likely to have a postoperative VTE event than predicted (O/E ratio 3.02, 95% CI 1.99-4.40). After implementing a mandatory VTE risk assessment model and a risk-commensurate prophylaxis protocol in the electronic medical record in 2011, the odds ratio of a patient developing a postoperative VTE declined to 0.70 by 2014 (95% CI 0.40-1.23). This success persisted through 2022.

CONCLUSIONS

Since the implementation of a standardized postoperative VTE prevention program in 2011, our institution has sustained a desirably low likelihood of VTE events in general surgery patients.

The Validation and Modification of the Caprini Risk Assessment Model for Evaluating Venous Thromboembolism after Joint Arthroplasty

BACKGROUND

 The Caprini risk assessment model (RAM) is the most commonly used tool for evaluating venous thromboembolism (VTE) risk, a high score for arthroplasty can result in patients being classified as high risk for VTE. Therefore, its value in post-arthroplasty has been subject to debate.

METHODS

 Retrospective data were collected from patients who underwent arthroplasty between August 2015 and December 2021. The study cohort included 3,807 patients, all of whom underwent a thorough evaluation using Caprini RAM and vascular Doppler ultrasonography preoperatively.

RESULTS

 A total of 432 individuals (11.35%) developed VTE, while 3,375 did not. Furthermore, 32 (0.84%) presented with symptomatic VTE, while 400 (10.51%) were detected as asymptomatic. Additionally, 368 (9.67%) VTE events occurred during the hospitalization period, and 64 (1.68%) cases were detected during postdischarge follow-up. Statistical analysis revealed significant differences between the VTE and non-VTE groups in terms of ages, blood loss, D-dimer, body mass index >25, visible varicose veins, swollen legs, smoking, history of blood clots, broken hip, percent of female, hypertension, and knee joint arthroplasty (p < 0.05). The Caprini score was found to be significantly higher in the VTE group (10.10 ± 2.23) compared with the non-VTE group (9.35 ± 2.14) (p < 0.001). Furthermore, there was a significant correlation between the incidence of VTE and the Caprini score (r = 0.775, p = 0.003). Patients with a score ≥9 are at a high-risk threshold for postoperative VTE.

CONCLUSION

 The Caprini RAM shows a significant correlation with the occurrence of VTE. A higher score indicates a greater likelihood of developing VTE. The score ≥9 is at particularly high risk of developing VTE.

Comparative study of two models predicting the risk of deep vein thrombosis progression in spinal trauma patients after operation

OBJECTIVE

Patients with preoperative deep vein thrombosis (DVT) exhibit a notable incidence of postoperative deep vein thrombosis progression (DVTp), which bears a potential for silent, severe consequences. Consequently, the development of a predictive model for the risk of postoperative DVTp among spinal trauma patients is important.

METHODS

Data of 161 spinal traumatic patients with preoperative DVT, who underwent spine surgery after admission, were collected from our hospital between January 2016 and December 2022. The least absolute shrinkage and selection operator (LASSO) combined with multivariable logistic regression analysis was applied to select variables for the development of the predictive logistic regression models. One logistic regression model was formulated simply with the Caprini risk score (Model A), while the other model incorporated not only the previously screened variables but also the age variable (Model B). The model's capability was evaluated using sensitivity, specificity, positive predictive value, negative predictive value, accuracy, F1 score, and receiver operating characteristic (ROC) curve. Nomograms simplified and visually presented Model B for the clinicians and patients to understand the predictive model. The decision curve was used to analyze the clinical value of Model B.

RESULTS

A total of 161 DVT patients were enrolled in this study. Postoperative DVTp occurred in 48 spinal trauma patients, accounting for 29.81% of the total patient enrolled. Model A inadequately predicted postoperative DVTp in spinal trauma patients, with ROC AUC values of 0.595 for the training dataset and 0.593 for the test dataset. Through the application of LASSO regression and multivariable logistic regression, a screening process was conducted for seven risk factors: D-dimer, blood platelet, hyperlipidemia, blood group, preoperative anticoagulant, spinal cord injury, lower extremity varicosities. Model B demonstrated superior and consistent predictive performance, with ROC AUC values of 0.809 for the training dataset and 0.773 for the test dataset. According to the calibration curves and decision curve analysis, Model B could accurately predict the probability of postoperative DVTp after spine surgery. The nomograms enhanced the interpretability of Model B in charts and graphs.

CONCLUSIONS

In summary, we established a logistic regression model for the accurate predicting of postoperative deep vein thrombosis progression in spinal trauma patients, utilizing D-dimer, blood platelet, hyperlipidemia, blood group, preoperative anticoagulant, spinal cord injury, lower extremity varicosities, and age as predictive factors. The proposed model outperformed a logistic regression model based simply on CRS. The proposed model has the potential to aid frontline clinicians and patients in identifying and intervening in postoperative DVTp among traumatic patients undergoing spinal surgery.

Factors associated with venous thromboembolic disease due to failed thromboprophylaxis

INTRODUCTION

Available evidence to identify factors independently associated with failed thromboprophylaxis (FT) in medical patients is insufficient. The present study seeks to evaluate in hospitalized patients, which clinical factors are associated with the development of FT.

MATERIALS AND METHODS

A case-control study nested to a historical cohort, comparing patients who developed failed thromboprophylaxis (cases) with those who did not (controls). Univariate and multivariate regression analysis was performed to define the factors associated with FT.

RESULTS

We selected 204 cases and 408 controls (52.4% men, median age 63 years). Medical patients were 78.4%. The most frequent thromboprophylaxis scheme was enoxaparin. In the failed thromboprophylaxis group, most of the embolic events corresponded to pulmonary embolism (53.4%). Among cases, BMI was higher (26.3 vs. 25 kg/m2, p < 0.001), as was the proportion of patients with leukocytosis > 13,000 (27% vs. 18.9%, p:0.22), and patients who required intensive care management (48% vs. 24.8%, p < 0.001). Factors independently associated with FT were BMI (OR1.04;95%CI 1.00-1.09, p:0.39), active cancer (OR:1.63;95%IC 1.03-2.57, p:0.04), leukocytosis (OR:1.64;95%CI 1.05-2.57, p:0.03) and ICU requirement (OR:3.67;95%CI 2.31-5.83, p < 0.001).

CONCLUSION

Our study suggests that the failed thromboprophylaxis is associated with high BMI, active cancer, leukocytosis, and ICU requirement. Future studies should evaluate whether there is benefit in adjusting the thromboprophylaxis scheme in patients with one or more of these factors.

The Benefits and Imperative of Venous Thromboembolism Risk Screening for Hospitalized Patients: A Systematic Review

Venous thromboembolism (VTE) is a major preventable condition in hospitalized patients globally. This systematic review evaluates the effectiveness and clinical significance of venous thromboembolism (VTE) risk-screening protocols in preventing VTE events among hospitalized patients. Databases, including PubMed, Embase and Cochrane, were searched without date limits for studies comparing outcomes between hospitalized patients who did and did not receive VTE risk screening using standard tools. Twelve studies, enrolling over 139,420 patients, were included. Study quality was assessed using the ROBVIS tool. The results were summarized narratively. The findings show significant benefits of using VTE risk screening versus usual care across various outcomes. Using recommended tools, like Caprini, Padua and IMPROVE, allowed for the accurate identification of high-risk patients who benefited most from prevention. Formal screening was linked to much lower VTE rates, shorter hospital stays, fewer deaths and better use of preventive strategies matched to estimated clot risk. This review calls for the widespread adoption of VTE risk screening as an important safety step for at-risk hospital patients. More high-quality comparative research is needed to validate screening tools in different settings and populations. In summary, VTE risk screening is essential for healthcare systems to reduce life-threatening VTE events and improve patient outcomes through properly targeted preventive methods.

Surgery As a Trigger for Incident Venous Thromboembolism: Results from a Population-Based Case-Crossover Study

Background  Surgery is a major transient risk factor for venous thromboembolism (VTE). However, the impact of major surgery as a VTE trigger has been scarcely investigated using a case-crossover design. Aim  To investigate the role of major surgery as a trigger for incident VTE in a population-based case-crossover study while adjusting for other concomitant VTE triggers. Methods  We conducted a case-crossover study with 531 cancer-free VTE cases derived from the Tromsø Study cohort. Triggers were registered during the 90 days before a VTE event (hazard period) and in four preceding 90-day control periods. Conditional logistic regression was used to estimate odds ratios (ORs) with 95% confidence intervals (CIs) for VTE according to major surgery and after adjustment for other VTE triggers. Results  Surgery was registered in 85 of the 531 (16.0%) hazard periods and in 38 of the 2,124 (1.8%) control periods, yielding an OR for VTE of 11.40 (95% CI: 7.42-17.51). The OR decreased to 4.10 (95% CI: 2.40-6.94) after adjustment for immobilization and infection and was further attenuated to 3.31 (95% CI: 1.83-5.96) when additionally adjusted for trauma, blood transfusion, and central venous catheter. In a mediation analysis, 51.4% (95% CI: 35.5-79.7%) of the effect of surgery on VTE risk could be mediated through immobilization and infection. Conclusions  Major surgery was a trigger for VTE, but the association between surgery and VTE risk was in part explained by other VTE triggers often coexisting with surgery, particularly immobilization and infection.