Managing Venous Thromboembolism Prophylaxis

---
name: managing-venous-thromboembolism-prophylaxis
language: en
description: Applies VTE risk assessment (Padua, Caprini) with appropriate prophylaxis selection. Use when assessing VTE risk, selecting prophylaxis regimens, or documenting DVT prevention.
tags:
  - management
  - hospital-medicine
  - risk
metadata:
  author: casemark
  practice_areas:
    - Hospital Medicine
    - Internal Medicine
  document_types:
    - Management Report
  skill_modes:
    - Management
    - Coordination
---

# Managing Venous Thromboembolism Prophylaxis

Applies VTE risk assessment (Padua, Caprini) with appropriate prophylaxis selection for hospitalized patients.

## Why This Skill Exists

Hospital-acquired venous thromboembolism (HA-VTE) is the leading preventable cause of hospital death, responsible for an estimated 100,000 deaths annually in the United States. Despite clear evidence for prophylaxis, studies show that 30-50% of at-risk hospitalized patients do not receive appropriate VTE prophylaxis. CMS considers VTE after total knee or hip replacement a Hospital-Acquired Condition (no additional payment), and The Joint Commission includes VTE prophylaxis as a core measure (VTE-1 and VTE-2).

The Padua Prediction Score (for medical patients) and Caprini Risk Assessment Model (for surgical patients) are the two most widely validated risk stratification tools. The American College of Chest Physicians (ACCP) CHEST Guidelines and the Society of Hospital Medicine IMPROVE trial provide evidence-based frameworks for prophylaxis selection. Hospitalists must assess VTE risk at admission, reassess daily, and document both the risk assessment and the prophylaxis decision (including when prophylaxis is withheld due to bleeding risk).

---

## Checkpoint A: Pre-Draft Intake (Mandatory)

Before assessing VTE risk and initiating prophylaxis, confirm:

1. Is this a **medical** or **surgical** patient? *(Default: Determines which risk model to use — Padua for medical, Caprini for surgical)*
2. What is the patient's **current mobility status**? *(Default: Per nursing assessment — ambulatory, limited mobility, bed rest)*
3. Does the patient have **active bleeding** or **high bleeding risk**? *(Default: Assess using IMPROVE Bleeding Risk Score)*
4. What is the patient's **platelet count** and **coagulation status**? *(Default: Review admission labs)*
5. Does the patient have a **history of VTE** (DVT or PE)? *(Default: Review PMH and ask patient)*
6. Is the patient on **therapeutic anticoagulation** for another indication? *(Default: If yes, prophylaxis is already covered)*
7. What is the patient's **weight** and **renal function** (CrCl)? *(Default: Affects dosing — enoxaparin requires CrCl > 30 mL/min for standard dosing)*
8. Does the patient have a **history of HIT** (heparin-induced thrombocytopenia)? *(Default: Contraindication to heparin products)*

### Documents to Request

- Admission labs (CBC, coagulation studies, BMP for CrCl calculation)
- Medication list (current anticoagulants, antiplatelets)
- Surgical history and recent procedure dates
- VTE history with prior treatment details
- Allergy list (specifically heparin allergy and HIT history)
- Current mobility assessment from nursing or PT
- Weight (actual body weight for dosing)
- Bleeding history and current bleeding risk factors

---

## Step 1: Calculate the Padua Prediction Score (Medical Patients)

| Risk Factor | Score |
|-------------|-------|
| Active cancer (treatment within 6 months, metastatic, or palliative) | 3 |
| Previous VTE (excluding superficial vein thrombosis) | 3 |
| Reduced mobility (bed rest ≥ 3 days) | 3 |
| Known thrombophilia (Factor V Leiden, prothrombin mutation, antiphospholipid syndrome, protein C/S deficiency, antithrombin deficiency) | 3 |
| Recent (≤ 1 month) trauma or surgery | 2 |
| Age ≥ 70 years | 1 |
| Heart failure or respiratory failure | 1 |
| Acute MI or ischemic stroke | 1 |
| Acute infection or rheumatologic disorder | 1 |
| Obesity (BMI ≥ 30) | 1 |
| Ongoing hormonal treatment (OCP, HRT) | 1 |

**Total score interpretation:**
| Score | Risk Level | Recommendation |
|-------|-----------|----------------|
| < 4 | Low risk | Ambulation; pharmacologic prophylaxis generally not indicated |
| ≥ 4 | High risk | Pharmacologic prophylaxis recommended (if not contraindicated) |

---

## Step 2: Calculate the Caprini Score (Surgical Patients)

| Points | Risk Factors |
|--------|-------------|
| **1 point each** | Age 41-60; minor surgery; BMI > 25; swollen legs; varicose veins; pregnancy or postpartum; history of unexplained stillborn, recurrent spontaneous abortion, premature birth; OCP or HRT; sepsis (< 1 month); serious lung disease (including pneumonia < 1 month); abnormal pulmonary function; acute MI; CHF (< 1 month); history of IBD; medical patient at bed rest |
| **2 points each** | Age 61-74; arthroscopic surgery; malignancy (present or previous); major surgery (> 45 min); laparoscopic surgery (> 45 min); patient confined to bed (> 72 h); immobilizing plaster cast; central venous access |
| **3 points each** | Age ≥ 75; history of SVT, DVT, or PE; family history of VTE; Factor V Leiden; prothrombin 20210A; lupus anticoagulant; anticardiolipin antibodies; elevated serum homocysteine; HIT (not including heparin products); other congenital or acquired thrombophilia |
| **5 points each** | Stroke (< 1 month); elective arthroplasty; hip, pelvis, or leg fracture; acute spinal cord injury (< 1 month) |

**Total score interpretation:**
| Score | Risk Level | Recommendation |
|-------|-----------|----------------|
| 0 | Very low risk | Early ambulation |
| 1-2 | Low risk | SCDs (mechanical prophylaxis) |
| 3-4 | Moderate risk | Pharmacologic prophylaxis OR SCDs |
| ≥ 5 | High risk | Pharmacologic prophylaxis AND SCDs |

---

## Step 3: Assess Bleeding Risk (IMPROVE Score)

Before initiating pharmacologic prophylaxis, assess contraindications:

| Bleeding Risk Factor | Score |
|---------------------|-------|
| Active gastroduodenal ulcer | 4.5 |
| Bleeding within 3 months before admission | 4 |
| Platelet count < 50,000 | 4 |
| Age ≥ 85 years | 3.5 |
| Hepatic failure (INR > 1.5) | 2.5 |
| Severe renal failure (GFR < 30 mL/min) | 2.5 |
| ICU/CCU admission | 2.5 |
| Central venous catheter | 2 |
| Rheumatic disease | 2 |
| Current cancer | 2 |
| Male sex | 1 |

**IMPROVE Bleeding Score ≥ 7**: High bleeding risk — use mechanical prophylaxis (SCDs) instead of pharmacologic. Reassess daily for transition to pharmacologic when bleeding risk decreases.

---

## Step 4: Select Appropriate Prophylaxis

| Clinical Scenario | Pharmacologic Prophylaxis | Mechanical Prophylaxis |
|------------------|--------------------------|----------------------|
| **Medical, high VTE risk, low bleed risk** | Enoxaparin 40 mg SQ daily OR heparin 5000 units SQ Q8h | Add SCDs if severely immobile |
| **Medical, high VTE risk, high bleed risk** | Contraindicated — use mechanical only | SCDs until bleeding risk resolves |
| **Medical, low VTE risk** | Not indicated | Early ambulation |
| **Surgical, Caprini ≥ 5** | Enoxaparin 40 mg SQ daily OR heparin 5000 units SQ Q8h | SCDs (both recommended) |
| **Surgical, Caprini 3-4** | Enoxaparin 40 mg SQ daily OR SCDs | Either mechanical or pharmacologic |
| **CrCl < 30 mL/min** | Heparin 5000 units SQ Q8h (enoxaparin requires dose adjustment: 30 mg SQ daily) | SCDs |
| **HIT history** | Fondaparinux 2.5 mg SQ daily | SCDs |
| **Morbid obesity (BMI > 40)** | Enoxaparin 40 mg SQ Q12h (weight-based dosing) OR heparin 7500 units SQ Q8h | SCDs |
| **Active therapeutic anticoagulation** | Not needed — already anticoagulated | Not needed |

---

## Step 5: Daily Reassessment and Documentation

Document VTE prophylaxis status at every daily round:

```
VTE PROPHYLAXIS ASSESSMENT

Date: [Date]
Risk score: Padua [X] / Caprini [X] — [Risk level]
Bleeding risk: IMPROVE [X] — [Low/High]
Current prophylaxis: [Medication + dose OR mechanical OR therapeutic anticoagulation]
Compliance: [SCDs worn? Injections given per MAR?]
Reassessment: [Any change in risk factors — new immobility, procedure, bleeding, 
              medication change]
Plan: [Continue current / Change to / Add / Discontinue — with rationale]
```

---

## Checkpoint B: Post-Draft Alignment (Mandatory)

For each patient's VTE prophylaxis:

1. Is the **VTE risk score** calculated and documented?
2. Is **bleeding risk** assessed before pharmacologic prophylaxis?
3. Is the **prophylaxis order** appropriate for the risk level and clinical scenario?
4. Has **renal function** been checked for enoxaparin dosing?
5. Is VTE prophylaxis **reassessed daily** with any change in clinical status?

---

## Quality Audit

- [ ] VTE risk assessment (Padua or Caprini) completed within 24 hours of admission
- [ ] Bleeding risk assessment (IMPROVE or equivalent) documented
- [ ] Pharmacologic prophylaxis ordered for high-risk patients without contraindication
- [ ] Mechanical prophylaxis (SCDs) ordered when pharmacologic is contraindicated
- [ ] Renal dose adjustment applied for CrCl < 30 mL/min
- [ ] Weight-based dosing applied for morbid obesity
- [ ] HIT history screened before heparin product initiation
- [ ] SCDs are actually worn (nursing compliance documented)
- [ ] VTE prophylaxis reassessed daily at rounds
- [ ] Prophylaxis held appropriately peri-procedure with restart plan documented
- [ ] Extended prophylaxis considered at discharge for high-risk patients (cancer, major orthopedic surgery)
- [ ] Rationale documented when prophylaxis is withheld (bleeding risk, contraindication)
- [ ] Therapeutic anticoagulation recognized as providing prophylaxis (no duplicate prophylaxis ordered)

---

## Guidelines

- Every hospitalized patient must have a VTE risk assessment and a documented prophylaxis decision — "no prophylaxis" must have a documented reason
- Mechanical prophylaxis (SCDs) is only effective when actually worn — order compliance checks and document in nursing assessments
- Enoxaparin is renally cleared — always check CrCl before ordering; switch to unfractionated heparin for CrCl < 30 mL/min
- Post-operative VTE prophylaxis should begin within 12-24 hours of surgery per ACCP guidelines (unless active bleeding)
- For major orthopedic surgery (hip/knee arthroplasty, hip fracture), extended prophylaxis for 35 days post-operatively is recommended
- Aspirin alone is not adequate VTE prophylaxis for medical patients — it is only accepted in certain post-surgical protocols per AAOS guidelines
- When pharmacologic prophylaxis is held for a procedure, document the restart time explicitly ("Resume enoxaparin 40 mg SQ at 6:00 PM post-procedure")
- Transitioning from prophylactic to therapeutic anticoagulation when VTE is diagnosed requires immediate dose change and documentation of the indication change