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Venous Thromboembolism Prophylaxis – Adult – Inpatient/Ambulatory

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1
Venous Thromboembolism Prophylaxis
– Adult – Inpatient/Ambulatory
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
EXECUTIVE SUMMARY ........................................................................................................... 3
SCOPE ................................................................................................................................... 3
METHODOLOGY .................................................................................................................... 4
DEFINITIONS.......................................................................................................................... 4
INTRODUCTION ..................................................................................................................... 5
RECOMMENDATIONS ............................................................................................................ 5
UW HEALTH IMPLEMENTATION ........................................................................................... 11
APPENDIX A. EVIDENCE GRADING SCHEME(S) ...................................................................... 12
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Contact for Content:
Name: Philip Trapskin, PharmD, BCPS – Drug Policy Program
Phone Number: (608) 263-1328
Email Address: ptrapskin@uwhealth.org

Contact for Changes:
Name: Anne Rose, PharmD - Pharmacy
Phone Number: (608) 263-9738
Email Address: arose@uwhealth.org

Guideline Author(s):
Jennifer Lai, PharmD, BCPS - Pharmacy

Coordinating Team Members:
Anne Rose, PharmD – Anticoagulation Stewardship
Eileen Shannon, PharmD – Pharmacy


Committee Approvals/Dates:
Inpatient Anticoagulation Committee: April 2010; October 2014; December 2016

Pharmacy & Therapeutics Committee
ξ Initial Review: April 2010
ξ Last Periodic Review: December 2016

Release Date: April 2017 | Next Review Date: December 2018




















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Executive Summary
Guideline Overview
This guideline is intended to provide recommendations for identifying individual venous
thromboembolism (VTE) risk and bleeding risks for adult hospitalized patients and to provide
recommendations for preventative therapies based on VTE and bleeding risk.

Key Revisions
1. Added clarifications/definitions for VTE risk factors

Key Practice Recommendations
1. Prevention of VTE in Hospitalized Patients1,4
1.1. All hospitalized patients should be evaluated for both bleeding and VTE risk within 24
hours of admission, upon transferring level of care, and periodically during the
hospital stay. (UW Health GRADE Moderate quality evidence, strong recommendation)

2. Evaluating VTE risk in medical patients
2.1 The Modified Padua Risk Assessment Model should be used to assess VTE risk in
medical patients.1,3,5 (UW Health GRADE Moderate quality evidence, strong
recommendation)
2.2 VTE prophylaxis in medical patients

3. Evaluating VTE risk in surgical patients
3.1 The Caprini Risk Assessment Model should be used to assess VTE risk in general
and abdominal-pelvic surgery patients.4,20 (UW Health GRADE Moderate quality
evidence, strong recommendation)
3.2 VTE prophylaxis in surgical patients

4. Evaluating VTE risk in Special populations
4.1 VTE prophylaxis in orthopedic surgery patients

Scope
Disease/Condition(s): Venous thromboembolism (VTE) prophylaxis.

Clinical Specialty:
All clinicians who provide care to adult hospitalized patients

Intended Users:
Physicians, Advanced Practice Providers, Pharmacists, Nurses

Objective(s): This clinical practice guideline is intended to provide recommendations for
identifying patients who are at risk for developing VTE, to provide recommended therapy
options to reduce the risk of VTE during hospitalization and to provide recommended therapy
options for extended VTE prophylaxis after hospital discharge.

Target Population: The recommendations within this guideline would apply to any adult
inpatient with the intent to remain hospitalized for greater than 24 hours or who are discharged
on extended VTE prophylaxis.

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Interventions and Practices Considered: The clinical interventions and practices
recommended in this guideline are for the use of VTE risk assessment scoring, bleeding risk
considerations, and therapy options for prevention of VTE. Practices may include utilizing the
Caprini risk assessment score for surgical patients and a Modified Padua risk assessment score
for medical patients. Therapy options to prevent VTE may include mechanical (e.g. sequential
compression devices) or pharmacologic (e.g. UFH, LMWH or fondaparinux).

Major Outcomes Considered: Major outcome considered for this guideline are new venous
thromboembolism and/or major bleeding.
Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches (e.g., PUBMED) were conducted by the guideline author(s) and
workgroup members to collect evidence for review. Expert opinion and clinical experience were
also considered during discussions of the evidence.

Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by external
organizations and/or arrived at a consensus through discussion of the literature and expert
experience. All recommendations endorsed or developed by the guideline workgroup were
reviewed and approved by other stakeholders or committees (as appropriate).

Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:
Recommendations developed by external organizations maintained the evidence grade
assigned within the original source document and were adopted for use at UW Health.

Internally developed recommendations, or those adopted from external sources without an
assigned evidence grade, were evaluated by the guideline workgroup using an algorithm
adapted from the Grading of Recommendations Assessment, Development and Evaluation
(GRADE) methodology (see Figure 1 in Appendix A).

Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for the rating scheme(s) used within this document.

Recognition of Potential Health Care Disparities: Under or uninsured patients may have
difficulty acquiring low molecular weight heparin or other agents commonly prescribed at
discharge when extended VTE prophylaxis is indicated. In some situations direct oral
anticoagulants may be considered. Thromboembolic risks without anticoagulant therapy should
be discussed with the patient. The medication assistance program may be able to assist with
acquiring medications.
Definitions
1. Extreme obesity – patients with a BMI > 40 kg/M2

2. Renal dysfunction – patients with a CrCl< 30 mL/min or evidence of stage 4 [eGFR 15-
29 mL/min/1.73M2] or 5 [eGFR < 15 mL/min/M2] renal dysfunction

3. Mechanical prophylaxis – methods may include graduated compression stockings (GCS),
intermittent pneumatic compression devices (IPC), and venous foot pumps (VFP).1
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Introduction
Hospital acquired VTE has been considered the most common cause of preventable death. Due
to the multitude of both patient specific risk factors and procedural risk factors it can be difficult
to determine who is at high risk for VTE.1,2 Additionally, the prevalence of hospital acquired VTE
has also been difficult to determine. Studies have reported hospital acquired VTE prevalence
rates anywhere between 0.8% - 11% depending on the patient population evaluated.1-3

There have been many risk factors identified in both the medical and surgical patient
populations that can increase the risk of developing VTE. This guideline provides
recommendations on the use of risk assessment models, validated in their respective patient
populations, with the intent to identify patients who are at high risk for VTE and to provide
recommendations for appropriate VTE prophylaxis modalities.

Recommendations

1. Prevention of VTE in Hospitalized Patients1,4
1.1. All hospitalized patients should be evaluated for both bleeding and VTE risk within 24
hours of admission, upon transferring level of care, and periodically during the
hospital stay. (UW Health GRADE Moderate quality evidence, strong recommendation)
1.2 Documentation of initial bleeding and VTE risk should occur in the medical record
within 24 hours of hospital admission or postsurgical procedure. (UW Health GRADE
Very low quality evidence, strong recommendation)
1.3 Reassessment of bleeding and VTE risk should occur in the medical record when
there is a change in medical condition or level or care. (UW Health GRADE Very low
quality evidence, strong recommendation)

2. Evaluation of Bleeding Risk
2.1 There is no universally validated model to assess bleeding risk.1 (UW Health GRADE
Low quality evidence, strong recommendation)
2.2 Factors with a strong association with bleeding in medical patients:1,2 (UW Health
GRADE Moderate quality evidence, strong recommendation)
2.2.1 Active gastroduodenal ulcer
2.2.2 Bleeding in the 3 months prior to admission
2.2.3 Platelet count < 50 x109/L

2.3 Factors with a strong association with bleeding in surgical patients:2 (UW Health
GRADE Moderate quality evidence, strong recommendation)
2.3.1 Active bleeding or previous major bleeding
2.3.2 Renal failure (CrCl < 30 mL/min)
2.3.3 Hepatic failure (INR > 1.5 without anticoagulants)
2.3.4 Thrombocytopenia
2.3.5 Acute stroke
2.3.6 Uncontrolled systemic hypertension
2.3.7 Concomitant use of anticoagulants, antiplatelets or thrombolytics

3. Evaluating VTE risk in medical patients
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3.1 A Modified Padua Risk Assessment Model should be used to assess VTE risk in
medical patients.1,3,5 (UW Health GRADE Moderate quality evidence, strong
recommendation) See Table 1.

Table 1: Modified Padua Risk Assessment Model1,3,6,7
Risk Factor Points
Critically Ill 4
Inflammatory Bowel Disease 4
Active Cancer 3
Previous VTE 3
Reduced Mobility 3
Thrombophilic Condition 3
Recent (< 1month) Trauma/Surgery 2
Age ≥ 70 years 1
Heart or Respiratory Failure 1
Acute Myocardial Infarction or Ischemic Stroke 1
Acute Infection or Rheumatologic Disorder 1
BMI ≥ 30 1
Ongoing Hormonal Treatment 1
Total Points
Low VTE Risk – no prophylaxis needed < 4
High VTE Risk – prophylaxis recommended > 4

3.1.1 Critically ill is defined as a patient being followed by a critical care service,
admitted under an ICU status, or has been admitted for stroke
3.1.2 Inflammatory bowel disease is limited to Crohn’s disease and ulcerative
colitis. Irritable bowel syndrome (IBS) is not considered inflammatory bowel
disease.
3.1.3 Active cancer is defined as local or distant metastases and with
chemotherapy or radiation in the previous 6 months
3.1.4 Reduced mobility is defined as anticipated bed rest with bathroom privileges
for at least 3 days, if immobile at baseline, or admitted from an outside facility
where they were immobile > 72 hours
3.1.5 Thrombophilic condition is defined as defects of antithrombin, protein C or S,
factor V Leiden, G20210A prothrombin mutation, heparin induced
thrombocytopenia or antiphospholipid syndrome
3.1.6 Heart or respiratory failure implies an admission for heart failure
exacerbation, asthma or COPD exacerbation, cystic fibrosis exacerbation or
admitted for continuous BiPAP.
3.1.7 Rheumatologic disorder examples: rheumatoid arthritis, Lupus, Sjögren’s
Syndrome
3.1.8 Ongoing hormonal treatment includes: oral contraceptives, estrogen
replacement or testosterone injections

3.2 Medical patients identified as high VTE risk should receive the corresponding
prophylaxis based on individual considerations. See recommendations in Table 2.
(UW Health GRADE Low quality evidence, strong recommendation)

Table 2: VTE Prophylaxis Regimens for High VTE Risk Medical Patients1,8-14
Patient
Population
VTE Prophylaxis Regimens

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Preferred Option Alternative Option
High VTE Risk Enoxaparin 40 mg SQ every 24 hrsa Heparin 5000 units SQ every 8-12 hrsa
Renal impairment
(CrCl < 30 mL/min)*

*Not on renal
replacement therapy
Heparin 5000 units SQ every 8-12 hrsa

Enoxaparin 30 mg SQ every 24 hrsb

Extreme obesity
(BMI > 40 kg/M2)
Enoxaparin 40 mg SQ every 12 hrsb Heparin 5000 units SQ every 8 hrsb
Low body weight
(weight < 50 kg)
Heparin 5000 units SQ every 8-12 hrsa Enoxaparin 30 mg SQ every 24 hrsc
High Bleeding Risk Intermittent pneumatic compression
devices (IPC)a
Graduated compression stockings
(GCS) or Venous foot pumps (VFP)c
a: UW Health GRADE Moderate quality evidence, strong recommendation
b: UW Health GRADE Low quality evidence, strong recommendation
c: UW Health GRADE Low quality evidence, weak/conditional recommendation

A single meta-analysis evaluating 12 randomized control trials comparing heparin every 8
hour and every 12 hour dosing regimens revealed similar VTE prevention outcomes. An
increase in major bleeding events was seen in the every 8 hour dosing regimen.11

A single meta-analysis evaluating 16 randomized control trials comparing heparin every 8
hours, every 12 hours and LMWH revealed similar VTE prevention outcomes with no
differences seen in major bleeding events.12


1.2.1 Enoxaparin is the preferred pharmacologic prophylaxis agent for medical
patients. (UW Health GRADE Moderate quality evidence, strong recommendation)
1.2.2 If UFH is heparin is used the every 12 hours dosing regimen is preferred.11,12
(UW Health GRADE Moderate quality evidence, strong recommendation)

Pooled data from 3 randomized trials evaluating the efficacy of GCS for the prevention of
VTE in medical patients showed no benefit in preventing DVT or PE. GCS did increase the
incidence of skin breakdown and ulcers. There are no published studies for the use of IPC or
VFP in medical patients. Two meta-analysis in surgical patients showed IPC reduced risk of
DVT with no effect on PE.15-17

3.2.3 When utilizing mechanical prophylaxis IPC devices are preferred (UW Health
GRADE Moderate quality evidence, strong recommendation)

3.3 Refusal of parenteral prophylaxis18,19
3.3.1 Oral anticoagulants may be considered in high VTE risk medical patients who
refuse parenteral VTE prophylaxis. (UW Health GRADE Low quality evidence,
weak/conditional recommendation)
3.3.2 Apixaban and rivaroxaban have both been studied in this patient population
versus enoxaparin. While similar outcomes in VTE prevention were seen
when compared to enoxaparin, higher major bleeding was also seen with
these agents.
3.3.3 Apixaban 2.5 mg by mouth twice daily (UW Health GRADE Moderate quality
evidence, strong recommendation)
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3.3.4 Rivaroxaban 10 mg by mouth daily (UW Health GRADE Moderate quality
evidence, strong recommendation)
3.3.5 Avoid use in patients with CrCl < 30 mL/min


4. Evaluating VTE risk in surgical patients
4.1 The Caprini Risk Assessment Model should be used to assess VTE risk in general
and abdominal-pelvic surgery patients.4,20 See Table 3. (UW Health GRADE Moderate
quality evidence, strong recommendation)

Table 3: Caprini Risk Assessment Model2,20
1 Point 2 Points 3 Points 5 Points
Age 41-60 Age 61-74 Age ≥ 75 Acute spinal cord injury
(< 1 mo)
Acute MI (<1 mo) Central venous
access
Established
thrombophilia
Elective lower extremity
arthroplasty
BMI > 25 Immobile > 72 hrs HIT Hip, pelvis, or leg
fracture (< 1 mo)
CHF exacerbation
(<1 mo)
Leg plaster cast or
brace
Hx of VTE Stroke (< 1 mo)
Hx of Inflammatory
Bowel Disease
Malignancy Family hx VTE
(1 degree relative)

Procedure with local
anesthesia
Surgery- arthroscopic
Swollen legs or
Varicose veins
Surgery > 45 mins
Sepsis (< 1 mo)
Serious lung dx
ex. Pneumonia (<1 mo)
1 point
(For Women Only)
Oral contraceptives or HRT
Pregnancy or postpartum (< 1 month)
Hx of unexplained stillborn infant, spontaneous
abortion (≥3), premature birth with toxemia or
growth restricted infant

4.1.1 Established thrombophilia is defined as factor V Leiden, G20210A
prothrombin mutation, antiphospholipid syndrome, lupus anticoagulant, and
heparin induced thrombocytopenia.2,20 (UW Health GRADE Moderate quality
evidence, strong recommendation)

4.2 Each risk factor is associated with a point value and the total risk score is cumulative.
Table 4 provides prophylaxis recommendations based on total risk score. (UW Health
GRADE Moderate quality evidence, strong recommendation)

Table 4: VTE Prophylaxis Recommendations Based on the Caprini Risk Assessment Score2,20
Points Risk Recommendation
0 Very Low VTE Risk Early and frequent ambulation
1-2 Low VTE Risk Mechanical Prophylaxis
3-4 Moderate VTE Risk and Low Bleed Risk Pharmacologic Prophylaxis
> 5 High VTE Risk and Low Bleed Risk Mechanical AND Pharmacologic Prophylaxis
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> 2 High Bleed Risk Mechanical Prophylaxis

4.3 Surgical patients identified as high VTE risk should receive the corresponding
prophylaxis based on individual considerations. See recommendations in Table 5.
(UW Health GRADE Low quality evidence, strong recommendation)
Table 5: VTE Prophylaxis Regimens for High VTE Risk General Surgery
Patients2,11-13,16,17,21,22
Patient
Population
VTE Prophylaxis Regimens

Preferred Option Alternative Option
High VTE Risk Heparin 5000 units SQ every 8-12 hrsa Enoxaparin 40 mg SQ every 24 hrsa
Renal impairment
(CrCl < 30 mL/min)*

*Not on hemodialysis
Heparin 5000 units SQ every 8-12 hrsa Enoxaparin 30 mg SQ every 24 hrsb

Bariatric Surgery Enoxaparin 40 mg SQ every 12 hrsa Heparin 5000 units SQ every 8-12 hrsc
Major Trauma Enoxaparin 30 mg SQ every 12 hrsa Heparin 5000 units SQ every 8-12 hrsc
Abdominal/Pelvic
Surgery for Cancer
Enoxaparin 40 mg SQ every 24 hrsb Heparin 5000 units SQ every 8-12 hrsc
High Bleed Risk Intermittent pneumatic compression
devices (IPC)a
Graduated compression stockings
(GCS) or Venous foot pumps (VFP)c
a: UW Health GRADE Moderate quality evidence, strong recommendation
b: UW Health GRADE Low quality evidence, strong recommendation
c: UW Health GRADE Low quality evidence, weak/conditional recommendation

Two meta-analyses in general surgery patients showed IPC versus no prophylaxis reduced
risk of DVT but did not reduce the risk of PE or mortality.23,24

4.3.1 When utilizing mechanical prophylaxis IPC devices are preferred.23,24 (UW
Health GRADE Moderate quality evidence, strong recommendation)

5. VTE Prophylaxis for Special Populations
5.1 Acute kidney injury (AKI) or chronic kidney disease (CKD)
5.1.1 UFH is the preferred agent for patients who are on renal replacement
therapy25 (UW Health GRADE Low quality evidence, strong recommendation)
5.1.2 Enoxaparin 30 mg every 24 hours may be considered9,10,14,25 (UW Health GRADE
Low quality evidence, weak/conditional recommendation)
5.1.2.1 Consider monitoring anti-Xa level after 7-10 doses to evaluate for
accumulation (UW Health GRADE Low quality evidence, weak/conditional
recommendation)
5.1.2.2 Goal anti-Xa 0.2-0.4 units/mL

5.2 Extreme Obesity8,10,14,25
5.2.1 Optimal thromboprophylaxis has not been established (UW Health GRADE Low
quality evidence, weak/conditional recommendation)
5.2.2 Enoxaparin 40 mg every 12 hours is the preferred agent for VTE prevention
in obese patients (UW Health GRADE Moderate quality evidence, strong
recommendation)
5.2.2.1 Routine anti-Xa monitoring is not recommended (UW Health GRADE
Very low quality evidence, weak/conditional recommendation)
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5.2.3 Prophylactic UFH has not been adequately studied in morbidly obese
patients (UW Health GRADE Low quality evidence, weak/conditional
recommendation)
5.2.3.1 May consider heparin 5000 - 7,500 units every 8 hours26-28 (UW Health
GRADE Low quality evidence, weak/conditional recommendation)

5.3 Orthopedic Surgery29-37
5.3.1 There is no validated VTE risk assessment model for orthopedic patients
5.3.2 Orthopedic surgery places patients at high risk for VTE but additional risk
factors also include: (UW Health GRADE Low quality evidence, strong
recommendation)
5.3.2.1 Cancer (current or previous history)
5.3.2.2 Previous history of VTE
5.3.2.3 Hypercoagulable state
5.3.2.4 Multiple trauma
5.3.2.5 Spinal cord injury
5.3.3 Recommendations for VTE prophylaxis in orthopedic surgery patients is listed
in Table 6.

Table 6: VTE Prophylaxis Regimens for Orthopedic Surgery Patients29-37
Total Hip Arthroplasty Total Knee Replacement
Enoxaparin 40 mg SQ every 24 hrsa Enoxaparin 30 mg SQ every 12 hrsa
Warfarin Target INR goal 1.8-2.2b Target INR goal 1.8-2.2b
Aspirin 81- 325 mg by mouth twice daily b 81 - 325 mg by mouth twice daily b
a: UW Health GRADE Moderate quality evidence, strong recommendation
b: UW Health GRADE Very Low quality evidence, strong recommendation

5.4 History of Heparin Induced Thrombocytopenia
5.4.1 Unfractionated and low molecular weight heparins are not recommended.38
(UW Health GRADE High quality evidence, strong recommendation)
5.4.2 Fondaparinux 2.5 mg SQ every 24 hours36 (UW Health GRADE Low quality
evidence, strong recommendation)


6. Extended duration VTE prophylaxis prescribed on discharge.
6.1 Bariatric surgery16,39
6.1.1 Recommended for patients with high VTE risk, low bleed risk and BMI > 55
kg/m2 (UW Health GRADE Moderate quality evidence, strong recommendation)
6.1.2 Enoxaparin 40 mg SQ every 12 hours for 10 days (UW Health GRADE
Moderate quality evidence, strong recommendation)

6.2 Abdominal or pelvic surgery for cancer40,41
6.2.1 Recommended for patients with a cancer diagnosis who received a traditional
laparotomy or vulvectomy and is either > 60 years or < 60 years old with a
history of VTE (UW Health GRADE Low quality evidence, strong recommendation)
6.2.2 Enoxaparin 40 mg SQ every 24 hours for 28 days (UW Health GRADE
Moderate quality evidence, strong recommendation)
6.2.3 If patient refuses 28 days of prophylactic therapy then enoxaparin or UFH
may be considered for 14 days (UW Health GRADE Low quality evidence, strong
recommendation)

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6.3 Orthopedic surgery (see Table 7 for VTE prophylaxis options)42,43
6.3.1 Total hip arthroplasty: 10-14 days (UW Health GRADE Moderate quality
evidence, strong recommendation)
6.3.2 Total knee arthroplasty: 10-14 days (UW Health GRADE Moderate quality
evidence, strong recommendation)
6.3.3 Hip fracture surgery: 10-14 days (UW Health GRADE Moderate quality evidence,
strong recommendation)
6.3.4 For major orthopedic surgery may consider extended prophylaxis to 35 days
(UW Health GRADE Low quality evidence, strong recommendation)

6.4 If patient refuses extended duration parenteral prophylaxis then oral prophylaxis may
be considered18,19 (UW Health GRADE Low quality evidence, strong recommendation)
6.4.1 See section 3.5 for recommendations

7. Anticoagulant Monitoring25
7.1 Platelets (PLT)
7.1.1 Baseline PLT must be obtained within 48 hours before startingheparin or
enoxaparin (UW Health GRADE very low quality evidence, strong recommendation)
7.1.2 Recheck PLT 24 hours after initiating heparin or enoxaparin therapy and
every other day thereafter for up to 14 days or until therapy is discontinued
(UW Health GRADE very low quality evidence, strong recommendation)
7.1.3 If PLT count decreases > 50% from baseline or if PLT count falls below 100 x
109/L; See Heparin Induced Thrombocytopenia – Adult- CPG (UW Health
GRADE very low quality evidence, strong recommendation)
7.2 Complete Blood Count (CBC)
7.2.1 Obtain a baseline CBC prior to initiating anticoagulant therapy (UW Health
GRADE very low quality evidence, strong recommendation)
7.2.2 Recheck CBC a minimum of every 3 days thereafter (UW Health GRADE very
low quality evidence, strong recommendation)

7.3 After hospital discharge PLT and CBC should be monitored only as clinically
indicated (UW Health GRADE very low quality evidence, strong recommendation)

UW Health Implementation
Potential Benefits:
The benefits of this guideline include reducing hospital acquired VTE events by providing a
method for screening medical and surgical patients for VTE risk using validated risk assessment
tools and providing recommendations for appropriate VTE prophylaxis therapies. Additionally,
this guideline provides recommendations for patient populations where data is limited or
controversial (ex. Obese patients).

Potential Harms:
While it is anticipated that hospital acquired VTE events will be reduced as high risk VTE
patients receive heparin based prophylactic therapies, there is the potential risk for increased
bleeding events. There is not a universally validated bleeding risk model to use system wide,
but this guideline does list risk factors that are associated with higher bleeding rates for both
medical and surgical patients. Additionally, prophylactic heparin based therapies have a lower
risk for bleeding than compared to therapeutic doses.


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Patient Resources
1. Health Facts For You #7522 – Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE)
Treatment and Prevention
2. Health Facts For You #6915 – Heparin (Unfractionated and Low Molecular Weight Heparin)
3. Health Facts For You #6900 – Warfarin (Coumadin®, Jantoven®)

Guideline Metrics
1. Performance Measure VTE 1: VTE prophylaxis received within 24 hours of admission or
documented reason why none received
2. Performance Measure VTE 2: VTE prophylaxis received within 24 hours of admission or
documented reason why none received for ICU patients
3. Performance Measure VTE 6: Potentially preventable VTE event
4. Patient Safety Indicator 12: Post-operative VTE events
5. Hospital acquired VTE events

Implementation Plan/Clinical Tools
1. Guideline will be posted on uConnect in a dedicated location for Clinical Practice Guidelines.
2. Recommendations from this guideline will be incorporated into the required VTE prophylaxis
section in all admission, transfer and post-operative order sets.
3. The risk assessment appendices will be provided as a hyperlink in the order sets.

Best Practice Alerts (BPA)
1. VTE risk assessment BPA for pharmacists

Order Sets & Smart Sets
Included in all admission, transfer, and postoperative order sets

Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all patients. It is
understood that some patients will not fit the clinical condition contemplated by a guideline and
that a guideline will rarely establish the only appropriate approach to a problem.
Appendix A. Evidence Grading Scheme(s)

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Figure 1. GRADE Methodology adapted by UW Health


GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate We are quite confident that the effect in the study is close to the true effect, but it
is also possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.

GRADE Ratings for Recommendations For or Against Practice
Strong The net benefit of the treatment is clear, patient values and circumstances
are unlikely to affect the decision.
Weak/conditional
Recommendation may be conditional upon patient values and
preferences, the resources available, or the setting in which the
intervention will be implemented.


References
1. Klein RC, Le H, Schulman S, et al. and M. Hassan Murad. Prevention of VTE in Nonsurgical
Patients: Antithrombotic Therapy and Prevention of Thrombosis,9th ed: American College of
Chest Physicians Evidence-Based Clinical Practice Guidelines Chest. 2012;141;e195S-e226S.
2. Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients:
Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest
Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e227S-77S.
3. Barbar S, Noventa F, Rossetto V, et al. A risk assessment model for the identification of
hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score. J
Thromb Haemost. 2010; 8(11):2450-2457.
4. Decousus H, Tupson VF, Bergman JF, et al. IMPROVE Investigators. Factors at admission
associated with bleeding risk in medical patients: findings from the IMPROVE investigators.
Chest. 2011;139(1):69-79.
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5. Germini F, Agnelli G, Fedele M, et al. Padua prediction score or clinical judgement for decision
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Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
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27. Beall J, Woodruff A, Hempel C, et al. Efficacy and safety of high-dose subcutaneous
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2010;375(9717):807-15.
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33. Bauer KA, Eriksson BI, Lassen MR, et al. Fondaparinux compared with enoxaparin for the
prevention of venous thromboembolism after elective major knee surgery. N Engl J Med.
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34. Rivaroxaban. In: DRUGDEX® System (internet database). Thomson Micromedex, Greenwood
Village, Colorado, USA. Available at http://www.thomsonhc.com (cited August 6, 2014)
35. Apixaban. In: DRUGDEX® System (internet database). Thomson Micromedex, Greenwood
Village, Colorado, USA. Available at http://www.thomsonhc.com (cited August 6, 2014)
36. Fondaparinux. In: DRUGDEX® System (internet database). Thomson Micromedex, Greenwood
Village, Colorado, USA. Available at http://www.thomsonhc.com (cited August 6, 2014)
37. Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VET in Orthopedic Surgery
Patients: Antithrombotic Therapy and Prevent of Thrombosis, 9th ed: American College of Chest
Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e278S-325S.
38. Linkins L, Dans AL, Moores LK, et al. Treatment and Prevention of Heparin-Induced
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Suppl):e419S-94S.
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thromboprophylaxis on venous thromboembolism rates after bariatric surgery: a prospective
comparison trial. Surg Endosc. 2008; 22(11): 2384-2391
40. Lyman GH, Khorana AA, Kuderer NM, et al. Venous thromboembolism prophylaxis and
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41. Schmeler KM, Wilson GL, Cain K. Venous thromboembolism rates following the implementation
of extended duration prophylaxis for patients undergoing surgery for gynecologic malignancies.
Gynecol Oncol. 2013; 128(2):204-208.
42. Falck-Ytter Y, Francis CW, Johanson N, et al. Prevention of venous thromboembolism in
orthopedic surgery patients: antithrombotic therapy and prevention of thrombosis, 9th ed:
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2012; 141: 278s-325s.
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patients undergoing elective hip and knee arthroplasty, Evidence based guidelines and evidence
report. September 24, 2011. http://www.aaos.org/research/guidelines/VTE/VTE_full_guideline.pef
(accessed August 21, 2014)
Appendix C. Modified Padua Risk Assessment Model – Adult – Inpatient – Venous
Thromboembolism (VTE) Prophylaxis – CPG

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

16



Risk factors for venous thromboembolism (VTE) in the medical patient
Risk Factor Points
Critically Ill 4
Inflammatory Bowel Disease 4
Active Cancer 3
Previous VTE 3
Reduced Mobility 3
Thrombophilic Condition 3
Recent (< 1month) Trauma/Surgery 2
Age ≥ 70 years 1
Heart or Respiratory Failure 1
Acute Myocardial Infarction or Ischemic Stroke 1
Acute Infection or Rheumatologic Disorder 1
BMI ≥ 30 1
Ongoing Hormonal Treatment 1


VTE prophylaxis recommendations based on risk score
Points Risk Recommendation
< 4 Low VTE Risk VTE prophylaxis not needed
> 4 High VTE Risk and Low Bleed Risk Pharmacologic Prophylaxis
High VTE Risk and High Bleed Risk Mechanical Prophylaxis


Patient
Population
VTE Prophylaxis Regimens

Preferred Option Alternative Option
High VTE Risk Enoxaparin 40 mg SQ every 24 hrs Heparin 5000 units SQ every 8-12 hrs
Renal impairment
(CrCl < 30 mL/min)*

*Not on renal
replacement therapy
Heparin 5000 units SQ every 8-12 hrs

Enoxaparin 30 mg SQ every 24 hrs

Extreme obesity
(BMI > 40 kg/M2)
Enoxaparin 40 mg SQ every 12 hrs Heparin 5000 units SQ every 8 hrs
Low body weight
(weight < 50 kg)
Heparin 5000 units SQ every 8-12 hrs Enoxaparin 30 mg SQ every 24 hrs
High Bleeding Risk Intermittent pneumatic compression
devices (IPC)
Graduated compression stockings
(GCS) or Venous foot pumps (VFP)









Appendix D. Caprini Risk Assessment Model – Adult – Inpatient – Venous Thromboembolism
(VTE) Prophylaxis – CPG

CPG Contact for Changes:
Name: Philip J Trapskin, PharmD, BCPS
Phone Number: 263-1328
Email Address: ptrapskin@uwhealth.org
Revised: 12/2016
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

17


Risk factors for venous thromboembolism (VTE) in the surgical patient
1 Point 2 Points 3 Points 5 Points
Age 41-60 years Age 61-74 years Age ≥ 75 Acute spinal cord injury
(< 1 month)
Acute MI (<1 month) Central venous access Established
thrombophilia*
Elective lower extremity
arthroplasty
BMI > 25 Immobile > 72 hours HIT Hip, pelvis, or leg fracture
(< 1 month)
CHF exacerbation (<1 month) Leg plaster cast or brace Hx of VTE Stroke (< 1 month)
Hx of inflammatory bowel
disease
Malignancy Family hx VTE
(1 degree relative)

Procedure with local
anesthesia
Surgery- arthroscopic
Swollen legs/ Varicose veins
(current)
Surgery > 45 mins
Sepsis (< 1 month)
Serious lung dx
ex. Pneumonia (<1 month)
1 point
(For Women Only)
Oral contraceptives or HRT
Pregnancy or postpartum (< 1 month)
Hx of unexplained stillborn infant, spontaneous abortion
(≥3), premature birth with toxemia or growth restricted
infant

VTE prophylaxis recommendations based on risk score
Points Risk Recommendation
0 Very Low VTE Risk Early and frequent ambulation
1-2 Low VTE Risk SCD
3-4 Moderate VTE Risk and Low Bleed Risk Enoxaparin or Heparin
> 5 High VTE Risk and Low Bleed Risk Enoxaparin or Heparin AND SCD
> 2 High Bleed Risk SCD

Patient
Population
VTE Prophylaxis Regimens

Preferred Option Alternative Option
High VTE Risk Heparin 5000 units SQ every 8-12 hrs Enoxaparin 40 mg SQ every 24 hrs
Renal impairment
(CrCl < 30 mL/min)*

*Not on hemodialysis
Heparin 5000 units SQ every 8-12 hrs Enoxaparin 30 mg SQ every 24 hrs

Bariatric Surgery Enoxaparin 40 mg SQ every 12 hrs Heparin 5000 units SQ every 8-12 hrs
Major Trauma Enoxaparin 30 mg SQ every 12 hrs Heparin 5000 units SQ every 8-12 hrs
Abdominal/Pelvic
Surgery for Cancer
Enoxaparin 40 mg SQ every 24 hrs Heparin 5000 units SQ every 8-12 hrs
High Bleed Risk Intermittent pneumatic compression
devices (IPC)
Graduated compression stockings
(GCS) or Venous foot pumps (VFP)

Appendix E. VTE Risk in the Surgical Orthopedic Patient – Adult – Inpatient – Venous
Thromboembolism (VTE) Prophylaxis – CPG

CPG Contact for Changes:
Name: Philip J Trapskin, PharmD, BCPS
Phone Number: 263-1328
Email Address: ptrapskin@uwhealth.org
Revised: 12/2016
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

18



Orthopedic VTE Risk Assessment

Elevated VTE risk*
ξ Cancer (current or previous history)
ξ Previous DVT or PE
ξ Hypercoagulable state
ξ Multiple trauma
ξ Spinal cord injury

* VTE risk assessments in the orthopedic population have not been validated. Surgery specific VTE risk
should outweigh a patient’s contributing individual risk. Above are additional patient-specific risk factors
for VTE that may be considered.


VTE prophylaxis recommendations based on risk

For moderate VTE risk one of the below should be selected (bolded preferred)
ξ Enoxaparin 40 mg subcutaneous every 24 hours
ξ Warfarin
ξ Aspirin
ξ Mechanical prophylaxis

For high VTE risk a pharmacologic agent AND mechanical agent should be selected (bolded
preferred)
ξ Enoxaparin 40 mg subcutaneous every 24 hours
ξ Warfarin
ξ Aspirin
ξ Mechanical prophylaxis






CPG Contact for Changes:
Name: Philip J Trapskin, PharmD, BCPS
Phone Number: 263-1328
Email Address: ptrapskin@uwhealth.org
Revised: 12/2016
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org