Prevention of venous thromboembolism in long term care: results of a multicenter educational intervention using clinical practice guidelines: part 2 of 2 (an AMDA Foundation project).

INTRODUCTION: Implementation of prophylaxis for venous thomboembolism (VTE) through risk assessment based on clinical practice guidelines (CPGs) is variably adopted in long term care facilities (LTCF). Current guidelines recommend venous thromboembolism prophylaxis (VTE-P) following risk assessment, individualized to patient status. In LTCF, differing comorbidity, life-expectancy, ethical, and quality-of-life issues may warrant a unique approach. This article examines VTE-P practices in LTCF before and after educational intervention to bring practice patterns consistent with CPGs. METHODS: Phase 1 (preceding article in this issue) identified current practice to assess risk and implement VTE-P (17 geographically diverse LTCFs, 3260 total beds). Phase 2 (educational intervention using CPGs) and Phase 3 (outcomes) reexamined VTE-P at the same 17 centers. RESULTS: The frequency of indications for VTE-P and contraindications to anticoagulation were similar during Phases 1 and 3 (all P > .05). In Phase 3, use of aspirin alone decreased more than 50% (P < .0005), whereas use of compression devices increased (P < .0005). Regression models predicted no relationship between any indication or contraindication and VTE-P in Phase 1 (all P > .05) but identified significant relationships between indication and contraindications and VTE-P in Phase 3 (P = .022 to P < .0005), suggesting adequate understanding of current CPGs following education as the basis for improved VTE-P. CONCLUSIONS: The study confirms the presence of significant comorbidity in LTC residents, many with indications for VTE-P, some with contraindications for anticoagulation. Following educational intervention, more residents received VTE-P, influenced by risk-benefit ratio favoring treatment. These findings suggest that even a modest educational intervention significantly improves provider knowledge pertinent to risk assessment consistent with CPG and more appropriate VTE-P.

Prevention of venous thromboembolism: practice patterns in 17 geographically diverse long term care facilities in the United States: part 1 of 2 (an AMDA Foundation project).

INTRODUCTION: Current guidelines recommend antithrombotic prophylaxis for venous thromboembolism (VTE) using risk assessment, factoring contraindications. This report represents a summary of current practice patterns to prevent VTE in long term care as Phase 1 of a 3-phase educational intervention study. PHASE 1 PARTICIPANTS: Participants were 376 new admissions/readmissions (77 ± 12 [SD] years; 67% female) from 17 geographically diverse long term care facilities (3260 total beds). MEASUREMENTS: The process describes current VTE prophylaxis (VTE-P) practices; a companion article describes the educational intervention (Phase 2) and outcome (Phase 3). Phase 1 data were collected on use of nonpharmacological measures and antithrombotic drugs for VTE-P between July and September 2009. RESULTS: Indications for VTE-P were evident in 85% of new admissions, of which two-thirds received VTE-P. Contraindications for anticoagulation were observed in 54.8% of admissions, including quality of life or patient/caregiver wishes. Logistic regression analysis predicted no relationship between any indication for or any contraindication to VTE-P and use of VTE-P, suggesting an inadequate understanding of current clinical practice guidelines. CONCLUSIONS: Residents of long term care have significant comorbidity that poses risk for VTE; although many received VTE-P, contraindications were common, warranting individualized considerations. The likelihood of VTE-P was greatest following orthopedic surgery, severe trauma, and medical illness.