VTE prophylaxis in a children's hospital: Practices and opportunities for improvement

Abstract

Background: Evidence-based data regarding treatment of venous thromboembolism (VTE) in pediatric patients is scant, extrapolated from adult studies, and comprised of consensus guidelines. Despite the rising incidence of VTE in pediatric patients, no data exists for VTE risk assessment and prophylaxis in hospitalized children. In December 2008, Cleveland Clinic Children's Hospital instituted the Pediatric Anticoagulation Management Program (PACMP), an initiative aimed at standardizing prophylaxis, diagnosis and treatment of thromboembolic events. The PACMP applies to admitted patients age >=16 or < 16 with weight >70 kg or BMI >30. Patients satisfying these criteria should be risk-assessed and placed on VTE prophylaxis as recommended. Objectives: This observational study was designed to examine behaviors surrounding VTE risk assessment and prophylaxis in a tertiary children's hospital. Design/Method: Distribution of risk assessment categories was extracted from the electronic medical records (EMRs) of patients age < 18 years admitted to the Children's Hospital during the same 3-month period preceding and immediately following PACMP implementation. Results: Of 1349 admissions in 2009, 489 were risk-assessed at admission, for a compliance rate of 36%. Of those assessed, 24 patients were assessed as "low risk," 13 as "moderate risk," 3 as "high risk," and 512 as "age < 18" (it is possible for a patient to be assessed more than once per admission). Of patients assessed as "age < 18," 47 were age >=16 and 12 were < 16 with weight >70 kg or BMI >30. According to the guidelines, these patients are potentially at increased risk of VTE. All patients who fell into this increased risk category were assessed as follows: 59 as "age < 18," 10 as "low risk," 6 as "moderate risk," 3 as "high risk;" 144 (64%) were not assessed at all. Conclusion: Implementation of guidelines for VTE prophylaxis has resulted in greater awareness of this topic at our institution. Expectedly, compliance is not optimal; a resident survey indicates that this part of the admission orders is just forgotten, and most residents do not feel qualified to assess VTE risk. This study has identified opportunities for improvement in our institutional practices, particularly with regard to order entry in the EMR and educational initiatives.