3.13 Deep Vein Thrombosis Prophylaxis

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Description of Indicator

Relationship to Quality Medical care should be timely and effective
Type of Indicator Hospital process, Hospital level
Proposed Data Source Trauma Registry
Definition Deep vein thrombosis (DVT) prophylaxis (pharmacological OR mechanical) prescribed within 24 hours of hospital admission per 100 patients
Numerator All patients age 18 years and older admitted to hospital with an injury diagnosis AND DVT prophylaxis (pharmacological OR mechanical) prescribed within 24 hours of hospital admission
Denominator All patients age 18 years and older admitted to hospital with an injury diagnosis
Benchmark Not specified at present
Risk Adjustment Not applicable

 

Summary
This indicator is intended to monitor DVT prophylaxis.


Panel Review
Panelists identified this as an important indicator. They suggested that focusing on a specific patient population may improve the measurement properties of this indicator, but could then unintentionally imply that DVT prophylaxis is of lower priority for patients not specified in the indicator. Panelists debated what would be the optimal patient population for evaluation of this indicator and highlighted evidence suggesting that DVT is common in injured patients and may be associated with spinal cord injuries, spinal fractures, older age, increasing ISS, blood transfusion, long bone fractures, pelvic fractures and head injuries68. Panelists also noted that an alternative approach would be to modify the indicator to capture both DVT prophylaxis as well as documentation of reasons for not prescribing prophylaxis. This approach was not adopted due to concerns that it would make the indicator more complex to implement.
The panel noted that evidence is strongest for pharmacological prophylaxis, but decided to include mechanical prophylaxis given unknown risk of hemorrhage in select patient populations (e.g. head injured) and its perceived widespread use in patients considered at risk of bleeding.


Trauma Center Review
Comments from the trauma centers emphasized the importance of this indicator. They noted that the indicator may be most beneficial if it focused on patients at highest risk of DVT. Centers also suggested that consideration be given to address both contraindications to DVT prophylaxis and for cases where DVT prophylaxis may not be warranted.
Some trauma centers also suggested that the proposed 24 hour time frame was too long and indicated that time frames of 8 or 12 hours may be more appropriate.


Review of Literature & Evidence
Face Validity: No studies identified.
Construct Validity: A systematic review by the EAST Practice Parameter Workgroup for DVT Prophylaxis in 2002 summarized that venous thromboembolism is common in severely injured patients and that the optimal mode of prophylaxis is unknown. The best current evidence is for the use of low molecular weight heparin, but evidence exists for the effectiveness of unfractionated heparin and various mechanical devices68.
Reliability: No studies identified.

Risk Adjustment: Not applicable.

Utilization: DVT Prophylaxis is used as a quality indicator by a small number of trauma centers: USA 3% (5/200), Canada 9% (3/35), Australasia 8% (1/12).


Source
DVT prophylaxis has been proposed by several patient advocacy groups as a quality indicator for hospitalized patients69.

 

References
68. Rogers FB, Cipolle MD, Velmahos G, Rozycki G, Luchette FA. Practice management guidelines for the prevention of venous thromboembolism in trauma patients: the EAST practice management guidelines work group. J Trauma. 2002;53(1):142-164.
69. Canadian Patient Safety Institute. Safer Healthcare Now! Preventing venous thromboembolism - updated resources now available! 2012; http://www.saferhealthcarenow.ca/EN/shnNewsletter/Pages/Preventing-Venous-Thromboembolism-%E2%80%93-Updated-resources-now-available!.aspx. Accessed July 8, 2012.