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Areas of improvement in thromboprophylaxis of hospitalized medical patients
Áreas de mejora en la tromboprofilaxis de pacientes médicos hospitalizados
M. Martín Asenjo
, J.M. Martín Guerra, I. Usategui Martín, L.A. Sánchez Muñoz
Corresponding author
Servicio de Medicina Interna, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
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Martín Asenjo, J.M. Martín Guerra, I. Usategui Martín, L.A. Sánchez Muñoz" "autores" => array:4 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Martín Asenjo" "email" => array:1 [ 0 => "miguel.martin.asenjo@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J.M." "apellidos" => "Martín Guerra" ] 2 => array:2 [ "nombre" => "I." "apellidos" => "Usategui Martín" ] 3 => array:2 [ "nombre" => "L.A." "apellidos" => "Sánchez Muñoz" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Medicina Interna, Hospital Clínico Universitario de Valladolid, Valladolid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Áreas de mejora en la tromboprofilaxis de pacientes médicos hospitalizados" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1877 "Ancho" => 3419 "Tamanyo" => 607686 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pocket guide disseminated among practitioners.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviation</span>: BMI, body mass index; GFR, glomerular filtration rate; ICU, intensive care unit; INR, international normalized ratio; IPC, intermittent pneumatic compression; LMWHs, low-molecular-weight heparins; UFH, unfractionated heparin; VTE, venous thromboembolism disease.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Venous thromboembolism (VTE) in nonsurgical patients represents 75% of all cases of VTE in hospitalized patients.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">1,2</span></a> Despite the effectiveness of thromboprophylaxis,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a> recent international<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">4</span></a> and national<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> studies have shown that the procedure is often omitted, reaching only 25–36% of medical patients.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Given the magnitude of the problem and to determine the adequacy of thromboprophylaxis in hospitalized medical patients in our setting and the potential areas for improvement, we conducted an observational descriptive study using the 2012 recommendations of the American College of Chest Physicians (ACCP) as the gold standard.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We included all patients hospitalized in the Department of Internal Medicine of University Clinic Hospital of Valladolid over 2 weeks, excluding those who were treated with long-term anticoagulation and those hospitalized for acute VTE. We collected demographic variables, the reason for hospitalization, contraindications for anticoagulation, risk factors for VTE and hemorrhage and the type of thromboprophylaxis.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Of the 191 hospitalized patients, 112 met the inclusion criteria and constituted the study population. The patients’ mean age was 75.1<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>15.5 years, 61 (46%) were women, and 48 (43%) had a glomerular filtration rate <60<span class="elsevierStyleHsp" style=""></span>mL/min. The most common reason for hospitalization was infectious diseases (44 patients, 39.2%).</p><p id="par0025" class="elsevierStylePara elsevierViewall">Twenty-six patients (23%) presented some contraindication for anticoagulation (in 94% of the cases, they were relative). One hundred patients (89%) had VTE risk factors, the most common of which were severe acute infection (43 cases, 42%), prolonged immobility (40 cases, 35%), diabetes mellitus (32 cases, 28%), bedridden for more than 4 days (26 cases, 23%), obesity (19 cases, 17%) and heart failure (16 cases, 14%).</p><p id="par0030" class="elsevierStylePara elsevierViewall">Sixty-nine patients (62%) had a high VTE risk (according to the Padua Prediction Score<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a> [<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>]), and 16 (14%) patients had a high hemorrhagic risk (score >7 on the hemorrhagic risk scale developed from the IMPROVE registry<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> [<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>]). Prophylactic treatment was started with low-molecular-weight heparin (LMWH) in 77 patients (69%); physical measures were not used in any case.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">In accordance with the 2012 ACCP recommendations, 62 patients (55%) received appropriate thromboprophylaxis, while 32 (29%) were overtreated and 18 (16%) were undertreated. Of the overtreated patients, 22 (69%) were patients with low-risk VTE treated with LMWHs, 7 (22%) were patients with high-risk VTE with LMWH doses greater than indicated, and 3 (9) were patients with high-risk VTE with high hemorrhagic risk or contraindication for pharmaceutical prophylaxis who were treated with LMWHs. As for the undertreated patients, 10 (55%) had high-risk VTE with no contraindication for prophylaxis and were not treated with LMWHs; 8 (44%) were patients with high-risk VTE with a high hemorrhagic risk or contraindication for pharmaceutical prophylaxis, who were not administered physical measures.</p><p id="par0040" class="elsevierStylePara elsevierViewall">This study revealed areas of improvement in the thromboprophylaxis practiced in our setting, given that its adequacy (55%) was lower than that of other national<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">5,9</span></a> and international studies.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">10</span></a> This is partly explained by the broad definition of overtreatment used in the study, which represented the leading cause of inadequacy (29% of all patients included in the study). Although most of the hospitalized patients had a high risk of VTE (62%) and therefore an indication for thromboprophylaxis, the rest of the patients did not require it. The use of objective VTE and hemorrhagic risk assessment scales would help improve the adequacy of thromboprophylaxis, thereby avoiding the almost systematic prescription of LMWHs during patient admission.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">As with other series, it is worth noting the scarce use of physical measures of thromboprophylaxis. Although there is no solid evidence of their use in medical patients, these physical measures are a good alternative for those with a high VTE risk and contraindication for LMWHs<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a> (9.8% of the patients in our series).</p><p id="par0050" class="elsevierStylePara elsevierViewall">Our center has therefore implemented improvement activities, such as updating the thromboprophylaxis protocol, the use of VTE and hemorrhage risk scales for adjusting the thromboprophylaxis to the patient's risk, the dissemination of these scales during training sessions with all department practitioners and through pocket guides (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). However, these passive methods are not sufficiently effective.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a> We will therefore continue getting feedback from practitioners, analyzing activity registries and following the protocol (individual/group benchmarking).</p><p id="par0055" class="elsevierStylePara elsevierViewall">In conclusion, the adequacy of thromboprophylaxis in hospitalized medical patients is low in our setting. We have started improvement measures (standardized protocols) as a first step in a broader strategy for the adequacy of thromboprophylaxis.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Martín Asenjo M, Martín Guerra JM, Usategui Martín I, Sánchez Muñoz LA. Áreas de mejora en la tromboprofilaxis de pacientes médicos hospitalizados. Rev Clin Esp. 2018;218:112–114.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1877 "Ancho" => 3419 "Tamanyo" => 607686 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pocket guide disseminated among practitioners.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviation</span>: BMI, body mass index; GFR, glomerular filtration rate; ICU, intensive care unit; INR, international normalized ratio; IPC, intermittent pneumatic compression; LMWHs, low-molecular-weight heparins; UFH, unfractionated heparin; VTE, venous thromboembolism disease.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0065" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fatal pulmonary embolism in hospitalised patients: a necropsy review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "R. 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