‘Door-to-prophylaxis’ as a novel quality improvement metric in prevention of venous thromboembolism following traumatic injury
Objective Venous thromboembolism (VTE) risk reduction strategies include early initiation of chemoprophylaxis, reducing missed doses, weight-based dosing and dose adjustment using anti-Xa levels. We hypothesized that time to initiation of chemoprophylaxis would be the strongest modifiable risk for V...
| Main Authors: | , , , , , , , |
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| Format: | Article |
| Language: | English |
| Published: |
BMJ Publishing Group
2024-04-01
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| Series: | Trauma Surgery & Acute Care Open |
| Online Access: | https://tsaco.bmj.com/content/9/1/e001297.full |
| _version_ | 1797194708950188032 |
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| author | Bryan A Cotton Thaddeus J Puzio Jan-Michael Van Gent Mariela Sandoval Thomas W Clements David E Lubkin Carter W Kaminski Jonathan K Bates |
| author_facet | Bryan A Cotton Thaddeus J Puzio Jan-Michael Van Gent Mariela Sandoval Thomas W Clements David E Lubkin Carter W Kaminski Jonathan K Bates |
| author_sort | Bryan A Cotton |
| collection | DOAJ |
| description | Objective Venous thromboembolism (VTE) risk reduction strategies include early initiation of chemoprophylaxis, reducing missed doses, weight-based dosing and dose adjustment using anti-Xa levels. We hypothesized that time to initiation of chemoprophylaxis would be the strongest modifiable risk for VTE, even after adjusting for competing risk factors.Methods A prospectively maintained trauma registry was queried for patients admitted July 2017–October 2021 who were 18 years and older and received emergency release blood products. Patients with deep vein thrombosis or pulmonary embolism (VTE) were compared to those without (no VTE). Door-to-prophylaxis was defined as time from hospital arrival to first dose of VTE chemoprophylaxis (hours). Univariate and multivariate analyses were then performed between the two groups.Results 2047 patients met inclusion (106 VTE, 1941 no VTE). There were no differences in baseline or demographic data. VTE patients had higher injury severity score (29 vs 24), more evidence of shock by arrival lactate (4.6 vs 3.9) and received more post-ED transfusions (8 vs 2 units); all p<0.05. While there was no difference in need for enoxaparin dose adjustment or missed doses, door-to-prophylaxis time was longer in the VTE group (35 vs 25 hours; p=0.009). On multivariate logistic regression analysis, every hour delay from time of arrival increased likelihood of VTE by 1.5% (OR 1.015, 95% CI 1.004 to 1.023, p=0.004).Conclusion The current retrospective study of severely injured patients with trauma who required emergency release blood products found that increased door-to-prophylaxis time was significantly associated with an increased likelihood for VTE. Chemoprophylaxis initiation is one of the few modifiable risk factors available to combat VTE, therefore early initiation is paramount. Similar to door-to-balloon time in treating myocardial infarction and door-to-tPA time in stroke, “door-to-prophylaxis time” should be considered as a hospital metric for prevention of VTE in trauma.Level of evidence Level III, retrospective study with up to two negative criteria. |
| first_indexed | 2024-04-24T06:00:35Z |
| format | Article |
| id | doaj.art-10c83bfb976c44449bd4519cddfd680b |
| institution | Directory Open Access Journal |
| issn | 2397-5776 |
| language | English |
| last_indexed | 2024-04-24T06:00:35Z |
| publishDate | 2024-04-01 |
| publisher | BMJ Publishing Group |
| record_format | Article |
| series | Trauma Surgery & Acute Care Open |
| spelling | doaj.art-10c83bfb976c44449bd4519cddfd680b2024-04-23T07:30:15ZengBMJ Publishing GroupTrauma Surgery & Acute Care Open2397-57762024-04-019110.1136/tsaco-2023-001297‘Door-to-prophylaxis’ as a novel quality improvement metric in prevention of venous thromboembolism following traumatic injuryBryan A Cotton0Thaddeus J Puzio1Jan-Michael Van Gent2Mariela Sandoval3Thomas W Clements4David E Lubkin5Carter W Kaminski6Jonathan K Bates7Department of Surgery, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USAGeneral Surgery, University of Texas McGovern Medical School, Houston, Texas, USADepartment of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USADepartment of Surgery, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USADivision of Trauma and Surgical Critical Care, The University of Texas Health Science Center at Houston, Houston, Texas, USADivision of Trauma and Surgical Critical Care, The University of Texas Health Science Center at Houston, Houston, Texas, USADivision of Trauma and Surgical Critical Care, The University of Texas Health Science Center at Houston, Houston, Texas, USAThe University of Texas Health Science Center at Houston, Houston, Texas, USAObjective Venous thromboembolism (VTE) risk reduction strategies include early initiation of chemoprophylaxis, reducing missed doses, weight-based dosing and dose adjustment using anti-Xa levels. We hypothesized that time to initiation of chemoprophylaxis would be the strongest modifiable risk for VTE, even after adjusting for competing risk factors.Methods A prospectively maintained trauma registry was queried for patients admitted July 2017–October 2021 who were 18 years and older and received emergency release blood products. Patients with deep vein thrombosis or pulmonary embolism (VTE) were compared to those without (no VTE). Door-to-prophylaxis was defined as time from hospital arrival to first dose of VTE chemoprophylaxis (hours). Univariate and multivariate analyses were then performed between the two groups.Results 2047 patients met inclusion (106 VTE, 1941 no VTE). There were no differences in baseline or demographic data. VTE patients had higher injury severity score (29 vs 24), more evidence of shock by arrival lactate (4.6 vs 3.9) and received more post-ED transfusions (8 vs 2 units); all p<0.05. While there was no difference in need for enoxaparin dose adjustment or missed doses, door-to-prophylaxis time was longer in the VTE group (35 vs 25 hours; p=0.009). On multivariate logistic regression analysis, every hour delay from time of arrival increased likelihood of VTE by 1.5% (OR 1.015, 95% CI 1.004 to 1.023, p=0.004).Conclusion The current retrospective study of severely injured patients with trauma who required emergency release blood products found that increased door-to-prophylaxis time was significantly associated with an increased likelihood for VTE. Chemoprophylaxis initiation is one of the few modifiable risk factors available to combat VTE, therefore early initiation is paramount. Similar to door-to-balloon time in treating myocardial infarction and door-to-tPA time in stroke, “door-to-prophylaxis time” should be considered as a hospital metric for prevention of VTE in trauma.Level of evidence Level III, retrospective study with up to two negative criteria.https://tsaco.bmj.com/content/9/1/e001297.full |
| spellingShingle | Bryan A Cotton Thaddeus J Puzio Jan-Michael Van Gent Mariela Sandoval Thomas W Clements David E Lubkin Carter W Kaminski Jonathan K Bates ‘Door-to-prophylaxis’ as a novel quality improvement metric in prevention of venous thromboembolism following traumatic injury Trauma Surgery & Acute Care Open |
| title | ‘Door-to-prophylaxis’ as a novel quality improvement metric in prevention of venous thromboembolism following traumatic injury |
| title_full | ‘Door-to-prophylaxis’ as a novel quality improvement metric in prevention of venous thromboembolism following traumatic injury |
| title_fullStr | ‘Door-to-prophylaxis’ as a novel quality improvement metric in prevention of venous thromboembolism following traumatic injury |
| title_full_unstemmed | ‘Door-to-prophylaxis’ as a novel quality improvement metric in prevention of venous thromboembolism following traumatic injury |
| title_short | ‘Door-to-prophylaxis’ as a novel quality improvement metric in prevention of venous thromboembolism following traumatic injury |
| title_sort | door to prophylaxis as a novel quality improvement metric in prevention of venous thromboembolism following traumatic injury |
| url | https://tsaco.bmj.com/content/9/1/e001297.full |
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