Evaluation of VTE Prophylaxis in Trauma Patients at a Large Community HospitalAuthors: Sarah Skaggs Gatewood and Jerry Robinson
Objectives:- Identify current recommendations for proper VTE prophylaxis in trauma patients.
- Explain the implementation of guideline directed VTE prophylaxis management.
- Compare VTE event rates before and after implementation.
Background/Purpose: In 2022, the American Association for the Surgery of Trauma/American College of Surgeons-Committee on Trauma published a clinical protocol with updated recommendations for inpatient venous thromboembolism (VTE) prophylaxis after trauma. The dosing of enoxaparin for VTE prophylaxis in trauma patients at Huntsville Hospital did not match these recommendations. Trauma patients are at an increased risk of VTE, including deep vein thrombosis and pulmonary embolism. Pharmacologic and mechanical VTE prophylaxes are often necessary to decrease the risk of thromboembolic events after a trauma occurs. This project seeks to explore previous institution-specific dosing based on age, renal function, and other factors, compared to updated dosing to match 2022 recommendations.
Methods: This single-center, pre-post implementation, quasi-experimental study evaluated adult patients 18 years of age or older admitted to Huntsville Hospital under the care of trauma services from January 1st, 2024, to January 31st, 2025. Data was collected from the electronic health record (EHR) and analyzed using descriptive statistics. The following pre-intervention and post-intervention data were collected: patient demographics, hospital length of stay, renal function, VTE prophylaxis dosing, lab monitoring, and risk factors. Patients were excluded if they had a length of stay less than 72 hours, did not receive any mechanical VTE prophylaxis, or if they transferred to a long-term facility. A classification of patients was made based on current VTE prophylaxis guidelines after the trauma algorithm published by the American Association for the Surgery of Trauma/American College of Surgeons-Committee on Trauma1. The primary endpoint was appropriate compliance with the 2022 algorithm for VTE prophylaxis post-trauma. Efficacy was assessed via anti-Xa monitoring, targeting a range of 0.2-0.4 units/mL, with 10 mg dosing adjustments for levels outside this range. Secondary endpoints included composite rates of deep vein thrombosis and pulmonary embolism, patient length of stay, days on VTE prophylaxis, and adverse drug events (ADEs) related to enoxaparin administration. Hospital-specific data and current policies were reviewed to identify areas of improvement, which included adherence to practice guidelines for VTE prophylaxis in trauma patients. Post-intervention data included the same metrics as listed for the pre-implementation data set. An ongoing quality review was performed in the post-intervention phase to identify potential changes and ensure compliance.
Results: A total of 160 patients (mean age, 50 years) were studied, 80 in the pre-implementation group and 80 in the post-implementation group, with similar baseline characteristics, risk scores, overall length of stay, and days on VTE prophylaxis between groups. Adherence to guidelines was noted to be overall 44% in the pre-implementation group and 84% in the post-implementation group for all patients included. No anti-Xa levels were checked in the pre-implementation phase. In the post-implementation phase, target range anti-Xa levels were achieved in 53 out of 80 patients (87%), with 43 patients (70%) having their first level within the target range. The incidence of VTE events was similar between groups but lower in the post-implementation phase, with only 9% of patients experiencing VTE events versus 13% in the pre-implementation phase.
Conclusion: The implemented order set and ongoing feedback integration lead to successful protocol implementation. Overall compliance with the 2022 published algorithm for post-trauma venous thromboembolism prophylaxis was achieved in 84% of patients. Anti-Xa monitoring post implementation occurred in 87% of patients versus zero prior to implementation. VTE events were less in the post implementation phase as well. An ongoing review will be continued to evaluate ordering options as well as opportunities to optimize monitoring and adherence.
Self-Assessment Question:What is the primary purpose of anti-Xa monitoring in patients?
- To assess renal function
- To evaluate anticoagulant effect of current dosing strategy for effectiveness and safety
- To monitor for potential allergic reactions
- To check for the development of deep vein thrombosis (DVT)
