Prevention of venous thromboembolism in long-term care: Time for action?

TY - JOUR

T1 - Prevention of venous thromboembolism in long-term care

T2 - Time for action?

AU - Dharmarajan, T. S.

AU - Norkus, Edward P.

N1 - Funding Information: T.S. Dharmarajan MD, FACP, AGSF Montefiore Medical Center, North Division, Bronx, New York, New York Medical College, Valhalla, New York Edward P. Norkus PhD, FACN Montefiore Medical Center, North Division, Bronx, New York, New York Medical College, Valhalla, New York To the Editor: It was invigorating to read 2 articles in the March 2010 issue of the Journal pertinent to venous thromboembolism (VTE) in long-term care (LTC); one attempted to develop a risk stratification tool for VTE and immobility to assist clinicians in the care of residents in LTC, 1 the second, an editorial, stated that although available research does not support specific pharmacological agents for patients at risk for VTE, this does not mean that risk reduction of any nature should not be used. 2 The editorial comments are appropriate, and perhaps it is time that more attention is paid to the entity of VTE prevention in LTC. The same issue carried a message that “we need to rethink the approach to measuring performance and try to improve quality of care and services” and that “vast improvements will be needed in applying principles and practices.” 3 This statement was supported by another editorial, calling for the organization (American Medical Directors Association [AMDA]) to lead the way in defining critical physician competencies. 4 All said, the March 2010 issue carries meaningful and powerful messages to the readership and providers of care in LTC. There is little doubt that the many mobility-restricted residents in LTC are also at risk for VTE, and that their risk becomes much greater at certain times in their lives, notably following acute illness, hospitalization, combinations of the two, or when a variable interplay of factors including disease, surgery, restricted mobility, and medications predispose the resident to venous thrombosis. These vulnerable stages may last days to weeks or for much longer periods of time. We currently recognize that deep vein thrombosis and consequent VTE are preventable disorders. However, data from well-conducted multicenter projects on the prevalence or incidence of VTE in long-term care are lacking. Additionally, our awareness of the prevalence of pulmonary embolism and consequent mortality specifically in nursing homes is minimal. Autopsies are scarce in LTC and deaths are often simply attributed to old age or to multiple comorbid processes that accompany aging. A recent review from Canada states that the true scope of the problem is unknown, and that one needs to consider VTE prophylaxis if the residents are definitely at high risk 5 ; further, undiagnosed pulmonary embolism was the cause of death in one study where autopsies identified pulmonary embolism in 40% of deaths that were unsuspected before patient demise. 6 Finally, a perception that LTC residents are not candidates for all forms of preventive measures may exist (although well-established and accepted practice patterns for prevention through immunizations for influenza and pneumococcal pneumonia are in place). Could there be possible barriers in the approach by providers to the issue of VTE prevention? The American College of Chest Physicians (ACCP) evidence-based guidelines 7 published in 2008 are elaborate, but largely applicable to the hospital settings rather than tailored to the differing residents and their specific needs in long-term care. The ACCP guidelines nevertheless provide a good foundation for AMDA to establish an approach. Other societies have commented and provided steps to prevent VTE based on the platforms of the ACCP publication. To their credit, the AMDA Foundation developed a tool kit on antithrombotic therapy in LTC, providing a detailed account largely extrapolated from several sources including earlier ACCP versions. Still, specific applications tailored to help providers meet the needs of residents in LTC require clarification. Further, the Foundation, using a grant, has recently attempted to study current practices in VTE prevention in LTC. Information was presented at the 2010 annual AMDA meeting, identifying the existing practice patterns on the prevention of VTE involving 376 residents in 17 LTC facilities across the United States. 8 The same project described a simple educational intervention that vastly improved the efforts in risk assessment and implementation of preventive measures for VTE at the same 17 LTCF for an additional 363 residents. 9 The educational methods used were inexpensive, but effective. There was creditable cooperation from the various site subinvestigators, demonstrating that such quality improvement processes are possible through education provided by AMDA or its Foundation. A detailed analysis of the data from this project is under way in preparation for manuscript submission and publication in the near future. Providers in LTC must recognize the “call to action.” 4 Clearly we need well-conducted research on risk assessment and prevention of VTE in LTC and develop guidelines tailored to help the provider of care to residents in the nursing home setting. It may be time for action!

PY - 2010/9

Y1 - 2010/9

UR - http://www.scopus.com/inward/record.url?scp=77956255385&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=77956255385&partnerID=8YFLogxK

U2 - 10.1016/j.jamda.2010.05.010

DO - 10.1016/j.jamda.2010.05.010

M3 - Letter

C2 - 20816344

AN - SCOPUS:77956255385

SN - 1525-8610

VL - 11

SP - 531

EP - 532

JO - Journal of the American Medical Directors Association

JF - Journal of the American Medical Directors Association

IS - 7

ER -