Standardized Thromboprophylaxis Increases Compliance and Reduces Venous Thrombotic Events (VTE) in Hospitalized Cancer Patients

Background: Venous thromboembolism (VTE) remains a major cause of morbidity and mortality in hospitalized patients with cancer. In 2007, both ASCO and the NCCN developed clinical practice guidelines to help prevent and treat thrombosis in patients with cancer. Adherence to these guidelines has led to successful reduction of VTE in hospitalized patients. Because noncompliance with anticoagulant prophylaxis was an ongoing problem at our institution, a standardized order set for thromboprophylaxis (TP) utilizing anticoagulant therapy was developed and implemented for patients with cancer diagnoses.

Methods: All patients admitted to the inpatient oncology unit with a cancer diagnosis were screened for VTE prophylaxis utilizing a standardized order set. Cancer diagnosis and other risk factors for VTE were recorded on the TP order set along with choice of anticoagulant TP. Treatment options included Lovenox 40 mg once subcutaneous (sc)daily for patients with normal renal function, lovenox 30 mg sc daily for creatinine clearance <30cc/min, heparin(h) 5000 units sc every 8 hours. Pneumatic compression devices were utilized in patients who had contraindications to anticoagulation. Exclusion criteria included patients already on therapeutic anticoagulation, active bleeding, and platelet count (plt) <50,000. TP was instituted upon admission and continued until discharge. Patients were clinically monitored for VTE for 4 weeks post discharge and if symptomatic, venous Dopplers, VQ and/or Spiral CT scans were performed. Retrospective review of all VTE events in hospitalized cancer patients occurring in the previous quarter prior to initiation of the standardized order set was performed and number of VTE events and length of stay (LOS) were compared to the treatment group.

Results: 100 cancer patients were admitted to the inpatient oncology unit from 4/08–7/08 with use of the standardized TP order set for all patients. 89 patients received TP as follows: 79 received lovenox 40 mg sc daily, 2 lovenox 30mg sc daily, 5 h 5000 units sc q 8 hours, and 3 flowtron boots. 11 patients did not receive TP for the following reasons: 6 were on therapeutic anticoagulation for previous VTE, 4 had a plt < 50,000, 1 had brain metastases with surrounding edema. Of those who did receive TP, no VTE occurred during hospitalization and for 1 month post discharge. No bleeding complications were seen. As compared to those patients treated with the TP order set, 20/207 (9.6%) non-surgical hospitalized patients with cancer developed VTE during their hospitalization in the previous quarter (p<0.01). Of these patients, 11 did not receive TP, and 9 patients received TP: 5 with flowtron boots, 2 short term TP lovenox which was discontinued prematurely, 2 h 5000 units sc 8 hours. The average LOS of patients managed utilizing the TP order set was 7.1 days compared to 19.0 days (p<0.0001) in hospitalized cancer patients with VTE events prior to use of the TP order set. Conclusion: Hospitalized cancer patients are at significant risk for the development of VTE. The implementation of a standard order set ensures compliance with TP and significantly reduces VTE events. LOS is significantly reduced in hospitalized cancer patients by preventing VTE.