An analysis of data from 90 hospitals in China from 2007 to 2016 showed that the hospitalization rate of VTE has risen from 3.2/100,000 to 17.5/100,000 in the past ten years;
At the same time, the DissolVE-2 study showed that the proportions of medium and high risk of VTE in surgical inpatients in China were 32.7% and 53.4%, respectively, and the proportion of the high risk of VTE in medical patients was 36.6%. The proportion of taking reasonable preventive measures was only 9.3% in surgery and 6.0% in medicine. This result is far lower than the 39.5%-58.5% VTE prevention rate reported in the 2008 ENDORSE study in a global multi-center survey. The increasing burden of disease and the serious shortage of prevention status in China in the past decade have highlighted the necessity of VTE prevention and control.
1. Key populations for VTE prevention and treatment in hospitals
Based on the available evidence-based medical evidence, the following seven groups of people are mostly at high risk of VTE, and attention should be paid to the quality of assessment and prevention:
Critically ill patients: including but not limited to patients admitted to surgical ICU (SICU), medical ICU (MICU), coronary care unit (CCU), emergency ICU (EICU), renal ICU (KICU), etc.;
Orthopedic surgery patients: including but not limited to hip/knee replacement patients, trauma surgery patients, spinal surgery patients, fracture surgery patients, etc.;
Tumor surgery patients: patients undergoing surgery for malignant tumors, including but not limited to surgical patients admitted to general surgery, thoracic surgery, urology, neurosurgery, etc. due to malignant tumors;
Patients hospitalized due to acute medical diseases: patients over 40 years old with congestive heart failure, acute respiratory disease, stroke, rheumatic disease, combined infection (such as sepsis, abdominal infection, etc.);
Patients with thrombophilia: including but not limited to admission to respiratory department, cardiology department, hematology department (such as definite hereditary thrombophilia, myeloproliferative disease or lymphoma), gastroenterology department (such as inflammatory bowel disease), nephrology department ( Such as nephrotic syndrome), rheumatology (such as primary or secondary antiphospholipid syndrome) and other hereditary or acquired thrombophilia patients;
Gynecological and obstetrical patients: gynecological patients, pregnancy and puerperium patients, etc.;
Longer hospitalization time or older patients: patients whose hospitalization time is ≥14 days in ophthalmology, ENT, and stomatology departments, or patients who are ≥70 years old, etc.
2. The key dynamic timing of VTE prevention and treatment in the hospital
VTE risk and bleeding risk are constantly changing during a patient’s hospital stay. Invasive operations such as surgery and anesthesia will increase the risk of VTE and bleeding, and remission of acute disease may also reduce the risk of VTE or bleeding. Therefore, patients need to be dynamically evaluated and prevented throughout the hospitalization period.
It is recommended to focus on the quality of assessment and prevention at three key dynamic points during hospitalization:
(1) Within 24 hours after admission;
(2) When the condition or treatment changes: such as surgery or interventional operation (within 24 hours before operation, during operation, and within 24 hours after operation), transfer to another department (within 24 hours after transfer), change of nursing level, reporting/stopping critical illness ( serious illness) and other special circumstances;
(3) Within 24 hours before discharge.
3. Core indicators for quality evaluation of VTE prevention and treatment in hospitals
Evaluation quality indicators mainly include VTE risk assessment rate, VTE medium-to-high risk ratio, bleeding risk assessment rate, and high-bleeding risk ratio.
It is recommended to select the appropriate assessment scale for VTE risk assessment for hospitalized patients:
Surgical patients: It is recommended to use the 2005 version of the Caprini scoring scale. According to different Caprini assessment scores, the risk of VTE can be divided into low risk (0-2 points), intermediate risk (3-4 points), and high risk (≥5 points).
Non-surgical patients: Padua scoring scale is recommended. According to different Padua assessment scores, the risk of VTE can be divided into low risk (0-3 points) and high risk (≥4 points).
Tumor patients: The Caprini and Khorana assessment scales are mainly used. The Caprini assessment scale tends to be suitable for tumor patients who need surgical treatment, and the Khorana assessment scale tends to be suitable for medical and outpatient tumor patients undergoing radiotherapy and chemotherapy. If conditions permit, the two scales can be used to score patients at the same time, and the follow-up treatment measures can be guided by those with higher risk stratification.
Pregnancy and puerperium patients: Referring to the relevant guidelines updated by various international authoritative obstetrics and gynecology academic institutions in recent years, the “Expert consensus on prevention, diagnosis and treatment of venous thromboembolism during pregnancy and puerperium” issued by the Obstetrics and Gynecology Branch of the Chinese Medical Association in April 2021 formulated “Risk factors and corresponding preventive measures for VTE during pregnancy and puerperium”. It is recommended to use this as a guide to standardize the prevention and treatment of obstetric VTE in clinical practice.
Inpatients in other specialties (such as pediatrics, psychiatry, etc.): There is currently no mature and applicable specialty assessment scale, and the Caprini and Padua assessment scales can be considered. With the update progress of relevant international and domestic guidelines, the corresponding specialist assessment scale should be selected in due course.