Venous Thromboembolism

Introduction

Welcome to the APSA Quality and Safety Committee Venous Thromboembolism (VTE) Toolkit. This toolkit is intended to help anyone who is interested in quality improvement on the management of the patient with VTE.

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Available toolkit projects are listed below. Many of the approaches described are evidence-based - some are not. These approaches have not been approved by APSA.

Venous Thromboembolism Guidelines for Pediatric Patients

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Although VTE is rare in the pediatric population, several institutions have instituted clinical practices guidelines to assist with prophylactic management.

For instance, the Children’s Hospital of Richmond created a Venous Thromboembolism Risk Assessment Score (VTRAS) for patients ranging from 1-14 years of age, admitted for more than 23 hours, with the intent of guiding prophylactic therapy.

Protocol:

Resources:

Stakeholders: surgeons, residents, patients, nursing staff, intensivists, hematologists/oncologists, pediatricians

Challenges and solutions:

A subcommittee of the Pediatric Trauma Committee was convened and challenged with creating algorithms to manage children at risk for VTE. Monthly meetings were conducted for approximately a year in order to review the literature, define inclusion/exclusion criteria, develop a scoring sheet, educate the stakeholders and introduce the plan.

Initially, only paper forms could be utilized, and the logistics on where the blank forms were stored, and what to do with them once completed, became problematic. Therefore, usage was very low. Moreover, the form was initially used for patients between 12-14 years old, which made it difficult for residents to remember.

Currently, the form is available electronically (via the EMR) which automatically populates for all patients admitted for more than 24 hours.

Links to published data (used to develop the protocol): [1][2][3][4][5][6][7][8][9][10][11][12].

Submitted by: Patty Lange, MD

Additional Implementers: Victoria Kuester, MD, Pediatric Orthopedics, ChoR at Virginia Commonwealth University (VCU)

St. Joseph’s Children’s Hospital in Tampa developed the BayCare Best Practice Guidelines which provides evidence-based criteria for VTE prophylaxis in patients 10-17 years old.

Brief project description:

VTE is one of the leading causes of hospital-acquired morbidity for children in the US. It significantly increases hospitalization costs and prolongs the length of stay. Therefore, it is important to identify risk factors for VTE in order to identify these hospitalized children at risk for hospital-acquired VTE (HA-VTE) and initiate timely prophylaxis.

An in-depth literature review of evidence-based practices, risk factors, and prevention for VTE in children was performed. A multidisciplinary team composed of physicians, pharmacy personnel, and nursing staff was created to develop guidelines that identified risk factors, created categories, and recommended prophylaxis for each category. The developed guidelines went through the proper approval bodies, including the Pediatric Trauma Service, St. Joseph’s Children’s Hospital Quality Council, and the Medical Executive Committee. It was subsequently adopted as a BayCare Best Practice Medical Standard.

Protocol:

Stakeholders: pharmacists, hematologists/oncologists, pediatric hospitalists, pediatric general surgeons, pediatric orthopedic surgeons, pediatric critical care physicians, evidence-based medicine specialists

Challenges and solutions:

  • Challenge:
    • Identifying VTE risk factors- given the lack of standard pediatric VTE prophylaxis guidelines, different specialists had varying ideas on risk factors that should be included.
  • Solution:
    • Reviewed multiple published VTE risk assessment models and compared the risk factors identified within these models. Based on the evidence from these models, a list of VTE risk factors was developed for local use.

Links to published data (used to develop the protocol): [7][13][14][15][16][17][18][19][20][21].

Submitted by: Grant Geissler, MD

Additional implementers:

  • Lena Charafi, Pharmacy
  • Erin Cockrell, MD, Medical Director of Chilldren’s Hematology & Oncology
  • Christina Canody, MD & Patricia O’Brien, MD, Pediatric Hospitalist Medicine
  • Jerril Green, MD, Medical Director of Pediatric Critical Care Medicine
  • Sirine Baltagi, Pediatric Critical Care Physician
  • Tracey Delucia, MD, Pediatric Orthopedic Surgery
  • Paul Lewis, MD & Pamela Morell, RN, Evidence-Based Medicine
Note to Editor: Please add a banner to read: Venous Thromboembolism Guidelines for Pediatric Trauma Patients

Venous Thromboembolism Guidelines for Pediatric Trauma Patients

Kentucky Children’s Hospital developed a clinical practice guideline for the use of VTE prophylaxis in pediatric trauma patients. It was developed by the Pediatric Interdepartmental Trauma Quality Assurance Committee, part of the ACS-verified Level I Pediatric Trauma Center.

Protocol:

Stakeholders: pediatric trauma patients (defined as < 16 years old), pediatric surgeons (subspecialties: general, neurosurgery, orthopedics), pediatric critical care physicians, nurses, pharmacists

Challenges and solutions:

VTE events are rare in pediatric trauma. The incidence of VTE is less than 1% in the general pediatric trauma population. Although rare, VTEs are potentially serious events. Pharmacologic prophylaxis against VTE is a reasonable strategy in critically injured adolescent trauma patients. The effectiveness of prophylaxis compared to its potential harms has not been proven in this population.

Links to published data (used to develop the protocol):[17][22][23].

Submitted by: John M. Draus, Jr., MD

Tampa General Hospital, an ACS Level I trauma center, also developed a QI project in an attempt to protocolize and standardize VTE prophylaxis in injured pediatric patients, specifically for patients from 13-15 years of age.

Protocol:

Resources:

Stakeholders: pediatric trauma team, orthopedic surgery, pediatric intensivists, pediatric hospitalists

Challenges and solutions:

The project was initiated due to significant variability regarding VTE prophylaxis in pediatric trauma patients with orthopedic injuries. The orthopedic surgeons had high variability in the manner and duration of VTE prophylaxis within their group. Additionally, the specifics of VTE prophylaxis would vary, month to month, with new resident teams. The push for guidelines came jointly from the trauma and medical teams, as there was always uncertainty regarding the specifics of the VTE prophylaxis. A review of the current data and literature regarding pediatric VTE was performed, as well as review of other hospitals’ pathways, in order to develop the local guidelines.

The initial versions dictated, more specifically, the mechanism for prophylaxis for each risk group. However, there was considerable pushback from the orthopedic surgeons which were adamant that, in addition to the medical and overall injury considerations, the variabilities in their operative techniques would require differing VTE prophylaxis. Several meetings with the orthopedic service were conducted, a firm consensus was not reached. The result is reflected in the final guideline stating that direct attending-to-attending discussions regarding VTE prophylaxis requirements would occur. This open-ended process was the only way the orthopedic service would sign off on the guidelines. In the end, a more uniform VTE prophylaxis was reached for low risk patients. There still remains a fair amount of variability in VTE prophylaxis in the higher risk patients with orthopedic injuries (particularly, femur and acetabular fractures) but less than during pre-guideline implementation. There has certainly been a decrease in resident to resident and resident to attending variability for VTE prophylaxis within the orthopedic service, as direct attending to attending discussions have improved communication between all the involved services.

Links to published data (used to develop the protocol): [17][18][22][24][25][26][27][28][29][30][31][32][33][34][35].

Submitted by: Henry L. Chang, MD

For recent research pertaining to the management of patients with VTE, please refer to the references [36][37][38][39][40].

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References

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  15. Branchford BR, Mourani P, Bajaj L, et al. Risk factors for in-hospital venous thromboembolism in children: a case-control study employing diagnostic validation. Haematologica. 2012;97(4):509-15.  [PMID:22133768]
  16. Mahajerin A, Branchford BR, Amankwah EK, et al. Hospital-associated venous thromboembolism in pediatrics: a systematic review and meta-analysis of risk factors and risk-assessment models. Haematologica. 2015;100(8):1045-50.  [PMID:26001789]
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  18. Atchison CM, Arlikar S, Amankwah E, et al. Development of a new risk score for hospital-associated venous thromboembolism in noncritically ill children: findings from a large single-institutional case-control study. J Pediatr. 2014;165(4):793-8.  [PMID:25064163]
  19. Arlikar SJ, Atchison CM, Amankwah EK, et al. Development of a new risk score for hospital-associated venous thromboembolism in critically-ill children not undergoing cardiothoracic surgery. Thromb Res. 2015;136(4):717-22.  [PMID:25979250]
  20. Reiter PD, Wathen B, Valuck RJ, et al. Thrombosis risk factor assessment and implications for prevention in critically ill children. Pediatr Crit Care Med. 2012;13(4):381-6.  [PMID:22198812]
  21. Sharathkumar AA, Mahajerin A, Heidt L, et al. Risk-prediction tool for identifying hospitalized children with a predisposition for development of venous thromboembolism: Peds-Clot clinical Decision Rule. J Thromb Haemost. 2012;10(7):1326-34.  [PMID:22583578]
  22. Hanson SJ, Faustino EV, Mahajerin A, et al. Recommendations for venous thromboembolism prophylaxis in pediatric trauma patients: A national, multidisciplinary consensus study. J Trauma Acute Care Surg. 2016;80(5):695-701.  [PMID:26881487]
  23. Petty JK. Venous thromboembolism prophylaxis in the pediatric trauma patient. Semin Pediatr Surg. 2017;26(1):14-20.  [PMID:28302279]
  24. Azu MC, McCormack JE, Scriven RJ, et al. Venous thromboembolic events in pediatric trauma patients: is prophylaxis necessary? J Trauma. 2005;59(6):1345-9.  [PMID:16394907]
  25. Brower LH, Kremer N, Meier K, et al. Quality Initiative to Introduce Pediatric Venous Thromboembolism Risk Assessment for Orthopedic and Surgery Patients. Hosp Pediatr. 2017;7(10):595-601.  [PMID:28899861]
  26. Chima RS, Hanson SJ. Venous Thromboembolism in Critical Illness and Trauma: Pediatric Perspectives. Front Pediatr. 2017;5:47.  [PMID:28349046]

  27. Multidisciplinary VTE Prophylaxis BESt Team, Cincinnati Children’s Hospital Medical Center: Best Evidence Statement Venous Thromboembolism (VTE) Prophylaxis in Children and Adolescents, http://www.cincinnatichildrens.org/service/j/anderson-center/evidence-based-care/bests/, BESt 181, pages 1-14, Date 2/18/14.


  28. Greenwald LJ, Yost MT, Sponseller PD, et al. The role of clinically significant venous thromboembolism and thromboprophylaxis in pediatric patients with pelvic or femoral fractures. J Pediatr Orthop. 2012;32(4):357-61.  [PMID:22584835]
  29. Landisch RM, Hanson SJ, Cassidy LD, et al. Evaluation of guidelines for injured children at high risk for venous thromboembolism: A prospective observational study. J Trauma Acute Care Surg. 2017;82(5):836-844.  [PMID:28430759]
  30. Murphy RF, Naqvi M, Miller PE, et al. Pediatric orthopaedic lower extremity trauma and venous thromboembolism. J Child Orthop. 2015;9(5):381-4.  [PMID:26459458]
  31. Raffini L, Trimarchi T, Beliveau J, et al. Thromboprophylaxis in a pediatric hospital: a patient-safety and quality-improvement initiative. Pediatrics. 2011;127(5):e1326-32.  [PMID:21464186]
  32. Thompson AJ, McSwain SD, Webb SA, et al. Venous thromboembolism prophylaxis in the pediatric trauma population. J Pediatr Surg. 2013;48(6):1413-21.  [PMID:23845640]
  33. Van Arendonk KJ, Schneider EB, Haider AH, et al. Venous thromboembolism after trauma: when do children become adults? JAMA Surg. 2013;148(12):1123-30.  [PMID:24173244]
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  35. Yen J, Van Arendonk KJ, Streiff MB, et al. Risk Factors for Venous Thromboembolism in Pediatric Trauma Patients and Validation of a Novel Scoring System: The Risk of Clots in Kids With Trauma Score. Pediatr Crit Care Med. 2016;17(5):391-9.  [PMID:26963757]
  36. Rothstein DH, Cairo SB, Schaefer BA, et al. Association of perioperative red blood cell transfusion with postoperative venous thromboembolism in pediatric patients: A propensity score matched analysis. Pediatr Blood Cancer. 2019;66(10):e27919.  [PMID:31298495]
  37. Cairo SB, Lautz TB, Schaefer BA, et al. Risk factors for venous thromboembolic events in pediatric surgical patients: Defining indications for prophylaxis. J Pediatr Surg. 2018;53(10):1996-2002.  [PMID:29370891]
  38. Landisch RM, Hanson SJ, Punzalan RC, et al. Efficacy of surveillance ultrasound for venous thromboembolism diagnosis in critically ill children after trauma. J Pediatr Surg. 2018;53(11):2195-2201.  [PMID:29997028]
  39. Betensky M, Bittles MA, Colombani P, et al. How We Manage Pediatric Deep Venous Thrombosis. Semin Intervent Radiol. 2017;34(1):35-49.  [PMID:28265128]
  40. Hanson SJ, Punzalan RC, Arca MJ, et al. Effectiveness of clinical guidelines for deep vein thrombosis prophylaxis in reducing the incidence of venous thromboembolism in critically ill children after trauma. J Trauma Acute Care Surg. 2012;72(5):1292-7.  [PMID:22673257]
  41. Cunningham AJ, Tobias J, Hamilton NA, et al. Significant practice variability exists in the prevention of venous thromboembolism in injured children: results from a joint survey of the Pediatric Trauma Society and the Trauma Center Association of America. Pediatr Surg Int. 2020;36(7):809-815.  [PMID:32488401]
Last updated: December 8, 2021