Prevention of venous thromboembolism in the critically ill patient.

Venous thromboembolism (VTE) contributes significantly to morbidity and mortality. The VITAE (VTE Impact Assessment Group in Europe) study estimated that each year in Europe almost 460,000 people develop deep vein thrombosis (DVT), including 300,000 cases of pulmonary embolism (PE). In the USA, annual incidence is reported as 150 per 100,000 of the population. The US Agency for Healthcare Quality and Research ranked appropriate use of venous thromboprophylaxis in patients at risk top of their list for widespread implications to patient safety. In 2005, the House of Commons Health Committee reported that an estimated 25,000 people in the UK die from preventable hospital-acquired VTE every year. This includes patients admitted to hospital for medical and surgical care. Amongst hospitalised patients, critical care admission is the strongest risk factor for VTE. This is a function of both the patient’s underlying disease process and acquired risk factors during an intensive care unit (ICU) stay including prolonged immobility, use of neuromuscular blockade and vasopressors, central venous catheter insertion and sepsis. VTE in this population can be expensive to diagnose and challenging to manage with a huge impact on morbidity and mortality. Up to 14% of post mortems in ICU patients demonstrate massive or submassive PE. Furthermore, hospital data show that improving VTE prophylaxis as part of compliance with a ventilator ‘bundle’ would contribute to reduced length of stay and free up a significant number of ICU bed days per annum. We can appreciate the disease burden of venous thromboembolic disease on a global scale and have witnessed a national drive forward in assessing the VTE risk for patients on admission to hospital. After implementing VTE Commissioning for Quality and Innovation (CQUIN) targets in the UK, risk assessment has risen to over 94%. NHS England reports that 3.4 million patients admitted to NHS acute care were risk assessed for VTE in the last quarter of 2013–2014. Greater focus on admission risk assessment has been shown to potentially reduce preventable VTE however, risk assessment must be followed by the appropriate intervention. The multinational cross sectional survey (ENDORSE) examined compliance rates to the American College of Chest Physicians (ACCP) guidelines for DVT prophylaxis and showed that in the UK, 50% of those assessed are at risk of VTE and only approximately 60% at risk are receiving recommended levels of prophylaxis.