Factors Affecting Clinical Decision Making in the Resumption of Anticoagulation after Trauma
Sarah Liu, Susan Campbell, Alia Aunchman
Surgery, University of Vermont Medical Center, South Burlington, Vermont, United States
Objective:
Millions of patients in the United States are on anticoagulation (AC) therapy. Meta-analyses have shown that AC reduces stroke risk in patients with atrial fibrillation by 60% though at the risk of increased bleeding complications. Unfortunately there are no clear guidelines regarding resumption of AC after trauma. Our aim is to determine how outpatient providers caring for trauma patients at the University of Vermont Medical Center (UVMMC) make these complex decisions, and whether the simple intervention of providing CHA2DS2-VASc and HAS-BLED scores at discharge would impact future AC management.
Design:
A retrospective cohort study of trauma patients on AC at the time of admission to UVMMC between January 2018 and December 2019 performed via phone survey and our trauma registry to collect Injury Severity Score (ISS), demographics, and whether AC was resumed. Prescribers of AC were then surveyed about factors influencing prescribing practices. In the future, we will add clinical scores to discharge summaries and reassess following intervention to see if AC practices change.
Setting:
A 620-bed academic hospital in Burlington, VT serving as a community hospital for the greater Burlington area and as a tertiary center for VT and northern NY.
Patients:
All patients ≥ 18 years of age admitted to the trauma service on AC at admission. 261 patients met inclusion criteria; ultimately 81 (31.0%) participated in the survey.
Interventions:
We created a new tool in Epic to calculate patients' CHA2DS2-VASc and HAS-BLED scores and import them into discharge summaries.
Main Outcome Measures:
Proportion of patients resuming AC following trauma before and after routine addition of clinical scores to patients' discharge summaries.
Results:
Of the 81 participants, 70 (86.42%) were restarted on AC, and 11 (13.58%) were not. Gender and age were not related to AC resumption (male 87.5% vs female 85.4%, p=0.6, age p=0.49). The mean time to AC resumption after trauma was 13.01±20.67 days (range 0 days to 120 days). ISS was significant with lower ISS resulting in increased rates of resumption (3.8±3.33) versus higher ISS (7.55±4.82, p= 0.0009).
Regarding the provider survey, 33 providers completed the survey. Of these, 26 (79.8%) indicated they treated patients on AC therapy who had had a traumatic injury, but only 12 (36.3%) reported they used clinical calculators to help guide their decision making. However, 29 respondents (87.9%) wished that these scores were provided to them.
Conclusions:
Decisions regarding resumption of AC after trauma can be individualized and difficult to standardize, and often involve multidisciplinary input. However, providing clinical scores at discharge may be a simple intervention which can aid these decisions. This may be shown with completion of the second half of our study.
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