Applies VTE risk assessment (Padua, Caprini) with appropriate prophylaxis selection. Use when assessing VTE risk, selecting prophylaxis regimens, or documenting DVT prevention.
Applies VTE risk assessment (Padua, Caprini) with appropriate prophylaxis selection for hospitalized patients.
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).
Before assessing VTE risk and initiating prophylaxis, confirm:
| 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) |
| 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 |
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.
| 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 |
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]
For each patient's VTE prophylaxis: