Evaluation of the applicability, efficacy, and safety of a thromboembolic event prophylaxis guideline designed for quality improvement of the traumatically injured patient.
BACKGROUND
Thromboembolic events (TE) such as deep venous thrombosis (DVT) and pulmonary embolism (PE) are common after trauma. Our Trauma Practice Management Committee developed an evidence-based DVT/PE prophylaxis guideline using a modified Delphi approach to standardize care and reduce TE rates. Our objective was to evaluate the applicability, efficacy, and safety of this guideline in the traumatized patient, especially those admitted first to the intensive care unit (ICU).


METHODS
We developed a risk-stratified DVT/PE prophylaxis guideline incorporating specific injuries, pertinent history, and physiologic parameters, favoring aggressive therapy in those at highest risk of dying from a PE. We prospectively collected data using this guideline in all patients admitted to the trauma or orthopedic-trauma services that were expected to stay for more than 48 hours (March-December 2003). Comparison was made with historical controls. Data collected included DVT, PE, prophylaxis level chosen, inferior vena cava filters, admission service and location, TRISS scores, length of stay, outcomes, adverse events, and specific risk factors.


RESULTS
TE rates after implementation of the guideline were lower than historical controls for all patients (1.9% vs. 1.0%, p = 0.059) and for patients admitted first to the ICU (6.3% vs. 2%, p = 0.018). Completed sheets were collected for 46% of the targeted population. No bleeding events caused by guideline anticoagulation were noted, and one death occurred after inferior vena cava filter placement. Nine of the 12 TEs in the treatment group were in patients with spine or closed-head injury, delaying chemical prophylaxis.


CONCLUSIONS
Form-based, risk-adjusted prophylaxis against TE leads to lower TE rates in a general and orthopedic ICU trauma population. Protocol compliance should be enforced.
Schuerer
Douglas J E
DJ
Department of Surgery, Burn, Trauma, Critical Care Section, Washington University, St. Louis, Missouri, USA. schuererd@wustl.edu
Whinney
Robb R
RR
Freeman
Bradley D
BD
Nash
Julie
J
Prasad
Sandip
S
Krem
Maxwell M
MM
Mazuski
John E
JE
Buchman
Timothy G
TG
D002985:Clinical Protocols; D003697:Delphi Technique; D006801:Humans; D017410:Practice Guidelines as Topic; D011655:Pulmonary Embolism / Q000517:prevention & control*; D018570:Risk Assessment; D020246:Venous Thrombosis / Q000517:prevention & control*; D014947:Wounds and Injuries / Q000150:complications / Q000628:therapy*