Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell CWPrevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 133: 381S-453S

Thromboembolism Program, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario, Canada.
Chest (Impact Factor: 7.48). 06/2008; 133(6 Suppl):381S-453S. DOI: 10.1378/chest.08-0656
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This article discusses the prevention of venous thromboembolism (VTE) and is part of the Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Grade 1 recommendations are strong and indicate that the benefits do or do not outweigh risks, burden, and costs. Grade 2 suggestions imply that individual patient values may lead to different choices (for a full discussion of the grading, see the "Grades of Recommendation" chapter by Guyatt et al). Among the key recommendations in this chapter are the following: we recommend that every hospital develop a formal strategy that addresses the prevention of VTE (Grade 1A). We recommend against the use of aspirin alone as thromboprophylaxis for any patient group (Grade 1A), and we recommend that mechanical methods of thromboprophylaxis be used primarily for patients at high bleeding risk (Grade 1A) or possibly as an adjunct to anticoagulant thromboprophylaxis (Grade 2A). For patients undergoing major general surgery, we recommend thromboprophylaxis with a low-molecular-weight heparin (LMWH), low-dose unfractionated heparin (LDUH), or fondaparinux (each Grade 1A). We recommend routine thromboprophylaxis for all patients undergoing major gynecologic surgery or major, open urologic procedures (Grade 1A for both groups), with LMWH, LDUH, fondaparinux, or intermittent pneumatic compression (IPC). For patients undergoing elective hip or knee arthroplasty, we recommend one of the following three anticoagulant agents: LMWH, fondaparinux, or a vitamin K antagonist (VKA); international normalized ratio (INR) target, 2.5; range, 2.0 to 3.0 (each Grade 1A). For patients undergoing hip fracture surgery (HFS), we recommend the routine use of fondaparinux (Grade 1A), LMWH (Grade 1B), a VKA (target INR, 2.5; range, 2.0 to 3.0) [Grade 1B], or LDUH (Grade 1B). We recommend that patients undergoing hip or knee arthroplasty or HFS receive thromboprophylaxis for a minimum of 10 days (Grade 1A); for hip arthroplasty and HFS, we recommend continuing thromboprophylaxis > 10 days and up to 35 days (Grade 1A). We recommend that all major trauma and all spinal cord injury (SCI) patients receive thromboprophylaxis (Grade 1A). In patients admitted to hospital with an acute medical illness, we recommend thromboprophylaxis with LMWH, LDUH, or fondaparinux (each Grade 1A). We recommend that, on admission to the ICU, all patients be assessed for their risk of VTE, and that most receive thromboprophylaxis (Grade 1A).

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Available from: Charles Marc Samama, Jun 16, 2015
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    • "Executable knowledge (i.e., decision support) was based upon guidelines and published evidence for identification of VTE risk, complications, and prevention. At the time of this study, the VTE prevention program was based on the eighth edition (the most currently available) of the American College of Chest Physicians' Antithrombotic Therapy and Prevention of Thrombosis guidelines (Geerts et al., 2008). These elements were created to screen at-risk patients, notify and advise the appropriate clinicians , and monitor for patient-specific events related to VTE. "
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    ABSTRACT: Despite venous thromboembolism (VTE) policy initiatives, gaps exist between guidelines and practice. In response, hospitals implement clinical decision support (CDS) systems to improve VTE prophylaxis. To assess the impact of a VTE CDS on reducing incidence of VTE, this study used a pretest/posttest, longitudinal, cohort design incorporating electronic health record (EHR) data from one urban tertiary and level 1 trauma center, and one suburban hospital. VTE CDS was embedded into the EHR system. The study included 45,046 admissions; 171,753 patient days; and 110 VTE events. The VTE rate declined from 0.954 per 1,000 patient days to 0.434 comparing baseline to full VTE CDS. Compared to baseline, patients benefitting from VTE CDS were 35% less likely to have a VTE. VTE CDS utilization achieved 78.4% patients assessed within 24 hr from admission, 64.0% patients identified at risk, and 47.7% patients at risk for VTE with an initiated VTE interdisciplinary plan of care. CDS systems with embedded algorithms, alerts, and notification capabilities enable physicians at the point of care to utilize guidelines and make impactful decisions to prevent VTE. This study demonstrates a phased-in implementation of VTE CDS as an effective approach toward VTE prevention. Implications for future research and quality improvement are discussed as well.
    Journal for Healthcare Quality 08/2015; 37(4):221-231. DOI:10.1111/jhq.12069 · 1.40 Impact Factor
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    • "Question à choix multiple avec plusieurs réponses possibles. correspondant à une pathologie pour laquelle la prescription d'un anti-thrombotique est recommandée par les sociétés savantes [3] [8] [9], telle que le cancer évolutif ou la lombalgie ou la lombosciatique aiguë ; 12,8 % (n = 86) des patients avaient une pathologie pour laquelle une thromboprophylaxie par HBPM (traumatisme ou AVC récent) était indiquée ; 2,5 % (n = 17) des patients avaient une indication qui relevait d'une AMM pour le fondaparinux 2,5 mg mais dans une indication autre que celle ayant fait l'objet de l'étude (infarctus du myocarde, post-chirurgie, événement thromboembolique veineux). Enfin, 22,1 % (n = 149) des patients avaient une pathologie ne pouvant être rapprochée ni des indications du RCP, ni des recommandations des sociétés savantes (fondaparinux et/ou HBPM) ni à aucune pathologie. "
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    ABSTRACT: Évaluer la durée moyenne de traitement par fondaparinux 2,5 mg à l’hôpital, dans son indication thromboprophylaxie en prévention médicale et décrire la population rejointe.
    Journal des Maladies Vasculaires 06/2015; DOI:10.1016/j.jmv.2015.05.001 · 0.24 Impact Factor
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    • "This form allowed the identification of variables that determined the risk group for each patient as well as the type of prophylaxis received. For the elaboration of the form and to determine the adequacy of the prophylaxis according to the risk of VTE, we used as a frame of reference the American College of Chest Physician (ACCP) guide, which was published in 2008 [9]. "
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    ABSTRACT: BACKGROUND: Venous thromboembolic disease (VTE) is associated with high morbi-mortality. Adherence rate to the recommendations of antithrombotic prophylaxis guidelines (ATPG) is suboptimal. The aim of this study was to describe the adequacy of antithrombotic prophylaxis (ATP) in hospitalized patients as the initial stage of a program designed to improve physician adherence to -ATP recommendations in Argentina. METHODS: This study was a multicenter, cross-sectional study that included 28 Institutions throughout 5 provinces in Argentina. RESULTS: 1315 patients were included, 729 (55.4%) were hospitalized for medical (clinical) reasons, and 586 (44.6%) for surgical reasons. Adequate ATP was provided to 66.9% of the patients and was more frequent in surgical (71%) compared to clinical (63.6%) subjects (p < 0.001). Inadequate ATP resulted from underuse in 76.6% of the patients. Among clinical, 203 (16%) had increased bleeding risk and mechanical ATP was used infrequently. CONCLUSIONS: The adequacy of ATP was better in low VTE risk clinical and surgical patients and high VTE risk in orthopedic patients. There was worse adequacy in high risk patients (with active neoplasm) and in those with pharmacological ATP contraindications, in which the use of mechanical methods was scarce. The adequacy of ATP was greater at institutions with < 150 beds compared with larger institutions. This is the first multicentric study reporting ATP in Argentina. Understanding local characteristics of medical performance within our territory is the first step in order to develop measures for improving ATP in our environment.
    Thrombosis Journal 07/2014; DOI:10.1186/1477-9560-12-15 · 1.31 Impact Factor
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