Maternal Safety Bundle for Venous...
Transcript of Maternal Safety Bundle for Venous...
Maternal Safety Bundle for Venous Thromboembolism
January 6, 2014
Venous Thromboembolism Bundle: Key Elements
• Risk assessment tools • Standardized approach
– Protocols for postnatal prophylaxis – Anesthesia checklist
• Suggested dosing schedule • Diagnostic algorithm for PE/DVT
Risk Assessment Tools
PREGNANCY INITIAL ASSESSMENT
History of VTE VTE Prophylaxis
Multiple VTE episodes Yes -> T*
1st VTE idiopathic Yes -> P*
1st VTE pregnancy/OC Related Yes -> P*
1st VTE provoked No
Inherited Thrombophilia carrier High Risk Low Risk
Yes -> T* Yes -> P*
Acquired Thrombophilia carrier Yes -> T*
Inherited Thrombophilia
High Risk Yes -> P*
Low Risk No
Acquired Thrombophilia No
Family History of VTE +High Risk (I+A) Yes -> P*/I
Fam Hx + low risk No
Risk Assessment
• High risk thrombophilia –FVL or PT gene homozygous, –Antithrombin deficiency, or –Combined disorders
• Low risk thrombophilia –FVL or PT gene heterozygous –Protein C or S deficiency
• Acquired thrombophilia –LA, ACA, APLS
• MTHFR or PAI-1 do not require prophylaxis
Risk Assessment: Pregnancy Re-Assessment
• B-1. Hospital admission for antepartum complications
(for conservative management not in labor, not scheduled for delivery.)
• B-2. Postpartum • B-3. On discharge
Risk Assessment: Antepartum Hospitalized B-1
• All receive SCD (sequential compression device) during hospitalization
• Add chemotherapy (LMWH/UFH) – Already receiving
prophylaxis/full anticoagulation
– Morbid obesity (BMI >40) – History of VTE – not
already on prophylaxis – All those with score 3 or
more risks
B-1 Antepartum Risk Factors
Thrombophilia – not already on prophylaxis
Age >40 years or <15 years
Medical complications
Pregnancy complication s (multiple, preeclampsia, IUGR)
Bed rest
Contraindications to LMWH Therapy
• Hemophilia or other known bleeding disorder (e.g. von Willibrand or acquired coagulopathy)
• Active or threatened antenatal bleeding (e.g. placenta previa, placental abruption)
• Thrombocytopenia (platelet count <75 x109)
• Stroke in previous 4/52 (hemorrhagic/ischemic) • Severe renal disease (GFR <30ml/min) • Severe liver disease (prolonged PT) • Uncontrolled hypertension (BP >200mmHg systolic or
>120mmHg diastolic)
Risk Assessment: Postpartum
• For cesarean delivery – SCDs prior to delivery
• For all vaginal and cesarean deliveries – Early mobilization, avoid dehydration – Add chemoprophylaxis if:
• Already receiving prophylaxis/full anticoagulation • History of VTE not already on chemoprophylaxis • Family history of VTE with any thrombophilia • Morbid obesity (BMI>40) • With score 2 or more (see B-1 + B-2 Risks)
Risk Assessment: Risk Factors
B-1 Antepartum Risk Factors B-2 Postpartum Risk Factors
Thrombophilia – not already on prophylaxis Any factors from B-1
Age >40 years or <15 years Cesarean section
Obesity (BMI >30) Peripartum Hemorrhage
Medical complications Hysterectomy
Pregnancy complication s (multiple, preeclampsia, IUGR) General Anesthesia
Bed rest Postpartum infection
Risk Assessment: Postpartum on Discharge
History of VTE VTE Prophylaxis
Multiple VTE episodes Yes -> T*
1st VTE idiopathic Yes -> P*
1st VTE pregnancy/OC Related Yes -> P*
1st VTE provoked Yes -> P*
Inherited Thrombophilia carrier High Risk Low Risk
Yes -> T* Yes -> P*
Acquired Thrombophilia carrier Yes -> T*
Inherited Thrombophilia
High Risk Yes -> P*
Low Risk No
Acquired Thrombophilia Yes ->P*
Family History of VTE +High Risk (I+A) Yes -> P*
Fam Hx + low risk No
VTE Prophylaxis at Discharge (at leas 6 weeks postpartum)
THERAPEUTIC HEPARIN/WARFARIN (one of the following)
Multiple VTE episodes
Single VTE + high risk thrombophilia
Single VTE + acquired thrombophilia
PROPHYLACTIC HEPARIN/WARFARIN (one of the following)
Single VTE unprovoked
Single VTE pregnancy or OC related
Single VTE provoked + Low Risk Thrombophilia
High risk Thrombophilia + No history of VTE
Acquired Thrombophilia + No history of VTE
Family History of VTE+ High risk or Acquired Thrombophilia
Low Risk Thombophilia; Family History of VTE+ Low Risk Thrombophilia DO NOT require DVT prophylaxis post discharge
VTE Prophylaxis at Discharge
Therapeutic Heparin/Warfarin
Prophylactic Heparin/Warfarin
One of the following:
• Multiple VTE • VTE with high risk
thrombophilia
One of the following:
• Any VTE episode • Low risk thrombophilia • Family history of VTE
with high risk thrombophilia
VTE Prophylaxis at Discharge
• Multiple VTE • Single VTE + High Risk
Thrombophilia • Single VTE + Acquired
Thrombophilia
• Single VTE Idiopathic • Single VTE Pregnancy/OC
Related • Single VTE Provoked • Single VTE+ Low Risk
Thrombophilia • High Risk Thrombophilia • Acquired Thrombophilia • Family history VTE + High Risk
Acquired Thrombophilia
THERAPEUTIC LMWH/UFH
for 6 weeks postpartum
PROPHYLACTIC LMWH/UFH
for 6 weeks postpartum
Post-Cesarean Thromboprophylaxis
• National data: – 1,263,205 women underwent cesarean
delivery between 2003-2010 – Perioperative and postpartum
thromboprophylaxis evaluated – Mechanical prophylaxis underused – Pharmacologic prophylaxis very rare
Post-Cesarean Thromboprophylaxis
0
10
20
30
40
50
60
70
80
90
100
2003 2004 2005 2006 2007 2008 2009 2010
None
Mechanical
Pharmacologic
Combination
Year of hospitalization
Perc
enta
ge o
f pat
ient
s
Prophylaxis:
Conclusion
Quality Data Measures
Measuring Care Quality
• Appropriate prophylaxis represents a major opportunity to reduce VTE
• How can improvements in care quality be best
measured?
VENOUS THROMBOEMBOLISM PROCESS MEASURES
1. % of obstetric patients who undergo a risk assessment for thromboembolism for any hospital admission:
a. Antepartum
b. Delivery
c. Postpartum
2. % of hospitals that offer educational resources and teaching tools for providers to assess thromboembolism risk during prenatal care:
VENOUS THROMBOEMBOLISM TREATMENT MEASURES
1. % of patients undergoing cesarean delivery who receive:
a. Mechanical prophylaxis
b. Heparin prophylaxis (+/- mechanical prophylaxis) universally or because of risk factors
2. % of patients who receive mechanical thromboembolism prophylaxis during:
a. Antepartum hospitalizations
b. Postpartum hospitalizations
c. Vaginal delivery hospitalizations
3. % of patients who receive heparin thromboembolism prophylaxis during:
a. Antepartum hospitalizations
b. Postpartum hospitalizations
c. Vaginal delivery hospitalizations
VENOUS THROMBOEMBOLISM OUTCOME MEASURES
1. Incidence of thromboembolism
a. Adjustment for comorbidities and risk factors
2. Type of thromboembolism
a. DVT
b. Pulmonary embolism
ACOG DISTRICT II VENOUS THROMBOEMBOLISM WORKGROUP
Mary D’Alton, MD (Co-Lead) Adiel Fleischer, MD (Co-Lead)
Richard Berkowitz, MD Robin D’Oria Robert Silverman, MD
Barry Brown, MD Alexander Friedman, MD Richard Smiley, MD
Steven Clark, MD (HCA) Deborah Karsnitz Georges Sylvestre, MD
Adriann Combs, MD Howard Minkoff, MD Anthony Vintzileos, MD
Ted Denious, MD Michael Paidas, MD (Yale) Richard Waldman, MD
Keith Eddleman, MD Alexander Shilkrut, MD Wendy Wilcox, MD
Jennifer Donnelly, MD