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Patterns of “Failure” of a Standardized Perioperative Venous Thromboembolism Prophylaxis Protocol
*Michael R Cassidy1, *Ryan Macht1, *Pamela Rosenkranz1, *Joseph A Caprini2, David McAneny1
1Boston University Medical Center, Boston, MA;2NorthShore University HealthSystem, Evanston, IL

Objective: To investigate patterns of “failure” after implementation of a highly effective perioperative risk-stratified venous thromboembolism (VTE) prophylaxis program.
Design: Case series.
Setting: An urban, academic, safety-net hospital.
Patients: All non-trauma General Surgery patients who had a documented VTE following the inception of a standardized VTE risk assessment and prophylaxis program.
Interventions: A mandatory electronic VTE risk assessment for every surgery patient, based upon the Caprini scoring system, along with risk-commensurate prophylaxis guidelines, including extended pharmacologic prophylaxis regimens when indicated. This system has reduced the odds ratio of a VTE event from 3.02 to 0.70.
Main Outcome Measures: Descriptive characteristics of patients who developed VTEs despite the Caprini system.
Results: 28 patients "failed" the VTE prophylaxis protocol over four years, an overall VTE rate of 0.3%. Of patients who developed VTEs, 64% had emergency operations, 57% underwent multiple operations, 21% had malignancies, but just 18% had missed ≥1 dose of pharmacologic prophylaxis during hospitalization (usually while in the OR). Five VTEs manifested following discharge, with one of those patients being prescribed extended prophylaxis, while an extended course was not provided to another patient who was eligible. A third patient had underestimation of the Caprini score due to prospective lack of awareness of a family history of VTE.
Conclusions: Emergency operations and multiple operations seem to confer dramatic hazards for VTEs despite standard prophylaxis. These factors are not currently captured in the Caprini risk model but may be significant modifiers of risk that should prompt re-assessment, perhaps with a weighted numeric value for Caprini score calculation along with “enhanced” prophylaxis. It is encouraging that most patients received appropriate prophylaxis in compliance with the protocol.


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