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01-03-2021 | Phlebothrombosis | Original Scientific Report

A Systems-based Approach to Reduce Deep Venous Thrombosis and Pulmonary Embolism in Trauma Patients

Authors: Navpreet K. Dhillon, Galinos Barmparas, Ting Lung Lin, Nikhil T. Linaval, Audrey R. Yang, Harveen K. Sekhon, Russell Mason, Daniel R. Margulies, Bruce L. Gewertz, Eric J. Ley

Published in: World Journal of Surgery | Issue 3/2021

Abstract

Background

Venous thromboembolism (VTE) in trauma patients carries significant morbidity and mortality. We previously described how titrating enoxaparin dosing by anti-Xa trough levels was associated with a lower VTE rate. We combined this strategy with a higher initial enoxaparin dose for a majority of patients and modified the electronic medical record (EMR) to encourage immediate dosing. We sought to determine if this systems-based approach was associated with a decrease in VTE rate.

Study Design

A retrospective review was conducted of all trauma patients on prophylactic enoxaparin at an academic, Level I Trauma Center from 01/2013 to 05/2014 (PRE) and 06/2015 to 02/2018 (POST). The patients in PRE were prescribed enoxaparin 30 mg twice daily without dose adjustments. The patients in POST received 40 mg twice daily unless exclusion criteria applied, with doses titrated to maintain anti-Xa trough levels between 0.1 and 0.2 IU/mL.

Results

There were 478 patients in the PRE and 1306 in the POST. Compared to PRE, POST patients were of similar age and were as likely to present after blunt trauma, although POST patients had lower injury severity scores (10 vs. 9, p < 0.01). The overall VTE rate was lower in POST (6.9% vs. 3.6%, p < 0.01). The adjusted risk of VTE (AOR 0.61, adjusted p = 0.04) was lower in POST and POST was independently protective for VTE (AOR 0.54; p = 0.01).

Conclusion

By implementing system changes to improve enoxaparin dosing after trauma, a significant reduction in VTE rate was observed. Wider application of this strategy should be considered.

Barrera LM, Perel P, Ker K, Cirocchi R, Farinella E, Morales Uribe CH (2013) Thromboprophylaxis for trauma patients. Cochrane Datab Syst Rev. https://doi.org/10.1002/14651858.CD008303.pub2CrossRef

Paffrath T, Wafaisade A, Lefering R, Simanski C, Bouillon B, Spanholtz T, Wutzler S, Maegele M, Registryof DGU Trauma (2010) Venous thromboembolism after severe trauma: incidence, risk factors and outcome. Injury 41(1):97–101CrossRef

Ruskin KJ (2018) Deep vein thrombosis and venous thromboembolism in trauma. Curr Opin Anaesthesiol 31(2):215–218. https://doi.org/10.1097/ACO.0000000000000567CrossRefPubMed

Ibrahim M, Ahmed A, Mohamed WY, El-Sayed Abu Abduo S (2015) Effect of compression devices on preventing deep vein thrombosis among adult trauma patients: a systematic review. Dimens Crit Care Nurs 34(5):289–300. https://doi.org/10.1097/DCC.0000000000000127CrossRefPubMed

Geerts WH, Jay RM, Code KI et al (1996) A comparison of low-dose heparin with low-molecular-weight heparin as prophylaxis against venous thromboembolism after major trauma. N Engl J Med 335(10):701–707. https://doi.org/10.1056/NEJM199609053351003CrossRefPubMed

Haas CE, Nelsen JL, Raghavendran K et al (2005) Pharmacokinetics and pharmacodynamics of enoxaparin in multiple trauma patients. J Trauma 59(6):1336–1343CrossRef

Rostas JW, Manley J, Gonzalez RP et al (2015) The safety of low molecular-weight heparin after blunt liver and spleen injuries. Am J Surg 210(1):31–34. https://doi.org/10.1016/j.amjsurg.2014.08.023CrossRefPubMed

Byrne JP, Mason SA, Gomez D et al (2016) Timing of pharmacologic venous thromboembolism prophylaxis in severe traumatic brain injury: a propensity-matched cohort study. J Am Coll Surg 223(4):621-631.e5. https://doi.org/10.1016/j.jamcollsurg.2016.06.382CrossRefPubMed

Nunez JM, Becher RD, Rebo GJ et al (2015) Prospective evaluation of weight-based prophylactic enoxaparin dosing in critically ill trauma patients: adequacy of antixa levels is improved. Am Surg 81(6):605–609CrossRef

10.

Berndtson AE, Costantini TW, Lane J, Box K, Coimbra R (2016) If some is good, more is better: an enoxaparin dosing strategy to improve pharmacologic venous thromboembolism prophylaxis. J Trauma Acute Care Surg 81(6):1095–1100. https://doi.org/10.1097/TA.0000000000001142CrossRefPubMed

11.

Ko A, Harada MY, Barmparas G et al (2016) Association between enoxaparin dosage adjusted by anti-factor xa trough level and clinically evident venous thromboembolism after trauma. JAMA Surg 151(11):1006–1013. https://doi.org/10.1001/jamasurg.2016.1662CrossRefPubMed

12.

Gennari JH, Musen MA, Fergerson RW et al (2003) The evolution of Protégé: an environment for knowledge-based systems development. Int J Hum Comput Stud 58(1):89–123. https://doi.org/10.1016/S1071-5819(02)00127-1CrossRef

13.

Gold AH, Malhotra A, Segars AH (2001) Knowledge management: an organizational capabilities perspective. J Manag Info Syst 18(1):185–214. https://doi.org/10.1080/07421222.2001.11045669CrossRef

14.

Kearon C, Akl EA, Ornelas J et al (2016) Antithrombotic therapy for VTE disease: chest guideline and expert panel report. Chest 149(2):315–352CrossRef

15.

Geerts WH, Code KI, Jay RM, Chen E, Szalai JP (1994) A prospective study of venous thromboembolism after major trauma. N Engl J Med 331(24):1601–1606CrossRef

16.

Malinoski D, Jafari F, Ewing T et al (2010) Standard prophylactic enoxaparin dosing leads to inadequate anti-Xa levels and increased deep venous thrombosis rates in critically ill trauma and surgical patients. J Trauma 68(4):874–880. https://doi.org/10.1097/TA.0b013e3181d32271CrossRefPubMed

17.

Costantini TW, Min E, Box K et al (2013) Dose adjusting enoxaparin is necessary to achieve adequate venous thromboembolism prophylaxis in trauma patients. J Trauma Acute Care Surg 74(1):128–133. https://doi.org/10.1097/TA.0b013e3182788fa7CrossRefPubMedPubMedCentral

18.

Ley EJ, Brown CV, Moore EE et al (2020) Updated guidelines to reduce venous thromboembolism in trauma patients: a western trauma association critical decisions algorithm. J Trauma Acute Care Surg. https://doi.org/10.1097/TA.0000000000002830CrossRefPubMedPubMedCentral

19.

Hunt DL, Haynes RB, Hanna SE, Smith K (1998) Effects of computer-based clinical decision support systems on physician performance and patient outcomes: a systematic review. JAMA 280(15):1339–1346CrossRef

20.

Catchpole K, Ley E, Wiegmann D et al (2014) A human factors subsystems approach to trauma care. JAMA Surg 149(9):962–968. https://doi.org/10.1001/jamasurg.2014.1208CrossRefPubMed

21.

Foster-Fishman PG, Nowell B, Yang H (2007) Putting the system back into systems change: a framework for understanding and changing organizational and community systems. Am J Commun Psychol 39(3–4):197–215. https://doi.org/10.1007/s10464-007-9109-0CrossRef

22.

Moch MK, Bartunek J (1987) First-order, second-order, and third-order change and organization development interventions: a cognitive approach. J Appl Behav Sci 23(4):483–500CrossRef

23.

Corrigan PW, Boyle MG (2003) What works for mental health system change: evolution or revolution? Adm Policy Ment Health 30(5):379–395CrossRef

Title: A Systems-based Approach to Reduce Deep Venous Thrombosis and Pulmonary Embolism in Trauma Patients
Authors: Navpreet K. Dhillon
Galinos Barmparas
Ting Lung Lin
Nikhil T. Linaval
Audrey R. Yang
Harveen K. Sekhon
Russell Mason
Daniel R. Margulies
Bruce L. Gewertz
Eric J. Ley
Publication date: 01-03-2021
Publisher: Springer International Publishing
Keywords: Phlebothrombosis
Enoxaparin
Published in: World Journal of Surgery / Issue 3/2021
Print ISSN: 0364-2313
Electronic ISSN: 1432-2323
DOI: https://doi.org/10.1007/s00268-020-05849-9

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

A Systems-based Approach to Reduce Deep Venous Thrombosis and Pulmonary Embolism in Trauma Patients

Abstract

Background

Study Design

Results

Conclusion

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Abstract

Background

Study Design

Results

Conclusion

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