Appropriateness of thromboprophylaxis in patients with medical conditions admitted from the emergency department: the PROTESU study

Jiménez Hernández S, Ruiz-Artacho P, Merlo Loranca M, Carrizosa Bach M, Aguillo García A, Antolín Santaliestra A, Llorens Soriano P

Objective: To assess the appropriateness of thromboprophylaxis in patients with medical

conditions admitted from the emergency department.

Methods: Prospective, multicenter cohort study in 6 Spanish hospital emergency

departments. Patients with medical conditions requiring hospital admission were

included between December 2011 and July 2012. The primary outcome was appropriate

use of thromboprophylaxis on admission from the emergency department;

appropriateness was defined according to the criteria in the PRETEMED guidelines.

Independent variables were demographic characteristics, comorbidity, personal medical

history, reason for admission, risk indicators during hospitalization, and risk factors for

hemorrhage.

Results: Of 610 patients recruited, data for 580 patients (mean [SD] age, 70.1 [16.9]

years; 45.3% women) were valid for assessment. The PRETEMED risk scale classified

44.1% of the patients as having moderate to high risk for venous thromboembolism

(VTE); 44.1% of these patients had indications for thromboprophylaxis but were not

receiving it on admission. Of the 55.9% of those at low risk for VTE, 29.6% received

thromboprophylaxis even though indicators did not suggest they required it. Medication

to prevent VTE was given inappropriately to 34.8% of the patients. Variables associated

with the decision not to order thromboprophylaxis in patients at moderate to high risk

were presence of a contraindication related to risk of hemorrhage (odds ratio [OR],

15.00; 95% CI, 4.61-48.67), admission on first evaluation rather than from the shortstay

unit (OR, 12.28; 95% CI, 1.35-113.12), high dependence at baseline (OR, 6.88,

95% CI, 1.59-29.83), polypharmacy (OR, 2.09; 95% CI, 1.00-3.69), malignant

hematologic disease (OR, 4.32; 95% CI, 0.85-21.83), and urinary tract infection (OR,

2.39; 95% CI, 0.90-6.37). The area under the receiver operating characteristic curve for

the model was 0.75 (95% CI 0.69-0.81).

Conclusions: Use of VTE prophylaxis was inappropriate in more than a third of the

patients in this cohort. Nearly half the patients for whom prophylaxis was indicated did

not receive it. Nonprescription of prophylaxis was associated with some risk factor for

hemorrhage, hospital admission from the emergency department as opposed to the

short stay unit, a high level of dependence, polypharmacy, urinary tract infection, and

malignant hematologic disease.

Aguillo García A, Antolín Santaliestra A, Carrizosa Bach M, Jiménez Hernández S, Llorens Soriano P, Merlo Loranca M, Ruiz Artacho P