Implementation Science Approaches to Optimizing Venous Thromboembolism Prevention in Patients with Traumatic Injuries: Findings from the 2022 Consensus Conference to Implement Optimal VTE Prophylaxis in Trauma

Abstract

Disease burden of venous thromboembolism (VTE) without pharmacologic prophylaxis is high in trauma patients. Although VTE prophylaxis guidelines exist, studies on real-world use of VTE prophylaxis in trauma shows limited uptake of guideline recommendations. Despite existing guidelines, reports indicate VTE prophylaxis implementation across trauma centers is lagging. Implementation barriers of VTE prophylaxis in trauma are multifactorial and VTE prescribing practices require further optimization. Implementation science methods can help standardize and improve care; well-established approaches in medical and surgical hospitalized patients and their effects on clinical outcomes such as VTE and bleeding complications must be investigated as they apply to trauma patients. Non-administration of VTE prophylaxis medications in hospitalized patients is associated with VTE events and remains a barrier to providing optimal defect-free care. Further investigations are required for VTE prophylaxis implementation across all trauma populations.

Social Media Summary:

VTE prophylaxis implementation in trauma patients needs further standardization. Investigation of current implementation methods in trauma centers is lacking and requires further study.

@nattrauma, #TraumaVTE22, #CNTR4U

Introduction

Venous thromboembolism (VTE) in trauma patients remains a significant cause of morbidity and mortality. The incidence of VTE in trauma patients is as high as 58% without prophylaxis. ^{(1, 2)} VTE, clinically manifested as a pulmonary embolism (PE) or deep venous thrombosis (DVT), has been demonstrated to increase healthcare costs and hospital length of stay.⁽³⁾ PE is the third leading cause of preventable mortality in hospitals and the number one cause of preventable mortality in trauma after the first 24 hours.⁽⁴⁾ VTE prevention is number 1 of 79 methods to improve patient safety in hospitals and is now listed as a top ten patient safety practice according to the Agency for Healthcare Research and Quality (AHRQ).^{(5, 6)} Many clinical practice guidelines have established that early and uninterrupted VTE prophylaxis administration is safe and effective. Interrupted VTE prophylaxis is associated with VTE events in both trauma⁽⁷⁾ and non trauma patients.⁽⁸⁾ Despite these guidelines, there is a paucity of evidence related to the implementation of VTE prophylaxis guidelines and to the actual delivery of VTE prophylaxis in trauma patients.⁽⁹⁾ Many observational and randomized controlled trials have studied implementation methods of VTE prophylaxis utilizing passive, active and multifaceted approaches (Table 1). While most of these studies have focused on hospitalized medical and surgical patients, the studies on trauma patients are scarce.^(10–30)

Table 1:

VTE Implementation Methods

Implementation Approach	Examples of Strategies
Passive	Distribution of guidelines which is audited and feedback given with performance review Preprinted and preset orders written or in electronic form
Active	Alerts which include Human alerts such as a pharmacist, trained nurse, process improvement coordinator or other staff Electronic alerts
Multifaceted	Combination of education, audit, feedback and alerts with an active strategy Education via grand rounds or self-administered testing/ course combined with an active strategy

Our objectives were twofold. First, we aimed to summarize existing guidelines in VTE prophylaxis in trauma patients. Second, we aimed to evaluate implementation science approaches of improving VTE prophylaxis in trauma patients and identify the gaps in VTE prophylaxis prescription and administration in order to enhance further investigations on this topic.

Background

Various evidence-based guidelines outline optimal VTE prevention in trauma patients (Supplemental Table 1). Providing “defect free care” as it applies to VTE prevention requires three critical steps, 1) a standardized risk assessment, 2) prescription of guideline recommended prophylaxis and 3) administration of all does of these medications.⁽³¹⁾ However, the disconnect between evidence and implementation of optimal VTE prophylaxis for all patients continue to be problematic. Non-adherence at each step is unfortunately common and has been underscored by several reports. A systematic review by Tooher et. al. found that “passive dissemination of guidelines is unlikely to improve VTE prophylaxis practice” and that multiple active strategies used together are more likely to result in optimal outcomes.⁽³⁰⁾ A survey conducted of the American Association for the Surgery of Trauma members demonstrated considerable variation in prescription of VTE prophylaxis in blunt solid organ injuries, with 30% of respondents denoting chemical prophylaxis was not indicated.⁽⁹⁾ Compliance with the Sixth American College of Chest Physicians (ACCP) Consensus Conference on Antithrombotic Therapy guidelines for the prevention of VTE in hospitals was found to be only 13.3% in 123, 304 hospital admissions, which included neurosurgical and orthopedic surgery patients.⁽¹⁰⁾ Louis et al., reported a major gap in medication administration in a prospective study of 202 trauma and general surgery patients, demonstrated that interrupted enoxaparin thromboprophylaxis occurred in 59% of patients aged 50 years and older.⁽⁷⁾ Furthermore, missed thromboprophylaxis doses were the only independent risk factors for VTE.

Implementation science is the “study of methods and strategies to promote the adoption and integration of proven clinical treatments, practices, organizational, and/or management interventions into routine practice and hence to improve health.”⁽³²⁾ The field of implementation science in surgery and trauma specifically remains in its infancy, but is likely the next great opportunity to improve patient care.^{(33, 34)} The implementation of specific strategies to increase adherence to VTE prophylaxis, has been studied in trauma and other patient populations. A Cochrane Review assessed VTE prophylaxis implementation interventions and their impact on VTE events.⁽¹¹⁾ Fifty-five studies were included, 8 of which were randomized controlled trials while the other 47 were non-randomized studies. Alerts, such as computerized reminders or stickers on patients’ charts, significantly increased the proportion of patients who received prophylaxis by 13%. Education and alerts were associated with a similar significant increase in prescription of appropriate prophylaxis. Multifaceted interventions, combining both active and passive approaches had the largest effects. The authors updated the review in 2018 and redemonstrated an increased prescription of VTE prophylaxis with alerts and multifaceted interventions.⁽¹²⁾ Computer alerts were particularly associated with a decrease in symptomatic VTE at three months. The analysis was however underpowered to assess the effect on mortality and bleeding outcomes. The same authors demonstrated that alerts not only increased the proportion of patients who received VTE prophylaxis by 21%, but also the incidence of symptomatic VTE events decreased by 35%.⁽³⁵⁾ This review, which included 13 RCTs, involved predominantly medical patients. In trauma patients, computerized clinical decision support has been shown to increase appropriate VTE prophylaxis prescription and decrease preventable harm from VTE.^{(36, 37)}

Even when best practice prophylaxis is prescribed to trauma patients, non-administration of regular pharmacologic prophylaxis may limit their effectiveness. Numerous studies have shown the association of VTE events with missed doses of VTE prophylaxis.^{(7, 8, 38, 39)}We must continuously strive for all steps of defect-free care to include evidence-based risk assessment, prescription of optimal prophylaxis, and administration of all prescribed doses of prophylaxis.⁽³¹⁾ Missed doses of VTE prophylaxis have been commonly identified at large academic hospitals (including trauma centers), as well as community hospitals.^{(40, 41)} Numerous multifaceted interventions have been shown to successfully decrease these missed doses. Educating nurses about the importance of VTE prophylaxis showed a 13 % decreased odds of missed doses in a cluster randomized education intervention trial.⁽⁴²⁾ A real-time, education bundle delivered by a health educator demonstrated a significant (nearly 50%) reduction of non-administration of VTE prophylaxis in both medical and surgical patients.⁽¹³⁾ Implementing this patient education bundle into routine clinical practice without the use of a dedicated, research-funded nurse educator has shown a similar effect size.⁽⁴³⁾

Evidence Gap

While evidence for the safety and efficacy of routine thromboprophylaxis implementation has grown, assessment of the impact of the various implementation interventions has lagged in all patient populations.⁽⁴⁴⁾ The trauma patients as a group are different from the average medical population who are included in many implementation studies. Trauma patients often have low socioeconomic status, high-risk occupational exposures and health behaviors, and lower educational background, and are at high risk for racial disparity.⁽¹⁰⁾ While thromboprophylaxis is recommended by multiple society guidelines in trauma (Table 2), a paucity of literature exists regarding implementation practices across trauma centers utilizing interventions that have been studied in medical and surgical hospitalized patients.^{(22–29, 45)}

Table 2:

Key Decisions in VTE Thromboprophylaxis Prescription in Trauma

Key Decisions in VTE Thromboprophylaxis Prescription in Trauma	Guidelines Supporting Key Decision
Use of low molecular weight heparin over unfractionated heparin in all trauma patients	NICE 2018 WTA 2020 AAST COT 2022
Use of intermittent pneumatic compression devices in patients at increased bleeding risk	ACCP 2012 BTFG 2017 NICE 2018 WTA 2020 AAST 2021
VTE prophylaxis initiation <72 hours in TBI patients	ACS TQIP 2015 BTFG 2017 NICE 2018 – 24-48 hours after cranial surgery with LMWH WTA 2020 - within 24 hours with a stable head CT WTA 2020 - VTE prophylaxis for all TBI patients <72 hours of time of injury AAST 2021 AAST COT 2022 – in low risk patients at 24 hours
VTE prophylaxis initiation in high risk TBI patients	AAST COT 2022 – in 72 hours
VTE prophylaxis initiation in SCI patients	NICE 2018 WTA 2020 AAST COT 2022
VTE prophylaxis initiation in solid organ injury patients once bleeding is stabilized	WTA 2020 - early VTE prophylaxis within 12–24 hours AAST 2021 - within 48 hours AAST COT 2022 – 24-48 hours
Against IVC filter placement	ACCP 2012 WTA 2020 AAST COT 2022
Against routine venous duplex ultrasound	ACCP 2012 WTA 2020 AAST 2021 AAST COT 2022

Reference: ACCP 2012⁵⁰, ACS TQIP 2015⁵¹, BTFG 2017⁵², NICE 2018⁵³, ASH 2019⁵⁴, WTA 2020⁵⁵, AAST 2021⁵⁶, AAST COT 2022⁵⁷

Despite these guidelines, it remains unclear if the guideline recommendations have affected thromboprophylaxis practices in the trauma population. Indeed, a wide practice variation exists among trauma surgeons and institutions as it relates to VTE prevention and diagnosis.^{(9, 46–48)} There are a number of challenges that influence real-world thromboprophylaxis in trauma. Trauma patients have considerable heterogeneity including the breadth of their injuries and their risks of VTE and bleeding. There is a fine clinical balance between states of hyper and hypocoagulability in the post-injury period. In addition, the multiple specialties and other stakeholders involved in trauma patient care often do not agree on specific practices, including the modality of thromboprophylaxis, dosing, timing of initiation, and duration. There is a need to achieve greater consistency within and between trauma centers. Furthermore, ensuring that patients actually receive the thromboprophylaxis that is prescribed is critical and has been under-studied. Multifaceted interventions, including standardized risk assessment tools, computerized clinical decision support, order sets, education of physician, nursing and pharmacy staff as well as of patients, routine audit and feedback, and root-cause analyses of trauma-associated events, both thromboembolic and bleeding, must be implemented to ensure optimal outcomes.

Future in VTE Implementation Research in Trauma

Patient outcomes, including clinically-important VTE and clinically-important bleeding require further study.⁽⁴⁹⁾ Thromboprophylaxis implementation science studies will inform how we should build better systems to prevent VTE in special trauma populations such as those with coagulopathy, traumatic brain injuries, solid organ injuries, orthopedic injury and spinal cord injuries.⁽⁴⁶⁾

Potential research questions in trauma VTE prevention:

• What is the current state of VTE prevention implementation at trauma and non-trauma centers?

• What strategies have already been implemented at trauma centers and non-trauma centers to improve guideline compliance?

• What are the VTE prophylaxis prescribing practices in special trauma populations with traumatic brain injuries, spinal cord injuries and solid organ injuries?

• What interventions have been shown to improve administration of all doses of prescribed VTE prophylaxis in trauma patients? Are there interventions that have been shown to work on non-trauma patients that could be used for trauma patients?

• For what surgical and/or other invasive procedures should VTE prophylaxis be held in trauma patients?

• What are the costs associated with implementation and non-implementation of clinical decision-support systems? Are they cost-effective?

Conclusions

Further investigations are required to identify potential facilitators to optimal care and overcome barriers to implementation of best practice prophylaxis for VTE prevention in trauma. Analysis of implementation science methods that have been studied in the medical and surgical population and its translation to the trauma population must be further examined.

Supplementary Material

Supplemental Data File (.doc, .tif, pdf, etc.)

SDC 1. Supplemental Table 1: Major VTE Prophylaxis Guidelines in Trauma