ORIGINAL ARTICLE
Venous Thromboembolism Risk Assessment and Prophylaxis Use in Pediatric, Adolescent, and Young Adult Hematology Oncology Patients Alison D. Bell, DNP,*w Marilyn Hockenberry, PhD,* Wendy Landier, PhD,z and Nadia Ewing, MDw
Summary: No widely accepted method exists to evaluate pediatric hematology oncology patients for the risk of venous thromboembolism (VTE) and the need for prophylaxis. The use of a VTE risk-assessment tool and standardized guidelines for prophylaxis could increase the use of appropriate prophylaxis and reduce the number of VTEs in patients, thereby decreasing morbidity, mortality, hospitalization, and cost. The purpose of this project was to implement and assess the compliance of a pediatric-specific VTE risk-assessment tool in hospitalized pediatric, adolescent, and young adult hematology oncology patients. From the 114 pediatric, adolescent, and young adult patients requiring assessment, 91 (80%) VTE assessments were completed and 87 (96%) were completed accurately. Eighty percent of the at-risk patients were ordered VTE prophylaxis. The use of a VTE risk-assessment tool in pediatric hematology oncology patients is a feasible way to assess patients for their risk of developing a VTE. Key Words: thrombosis, pediatric oncology, risk assessment, screening
(J Pediatr Hematol Oncol 2015;00:000–000)
T
he development of a venous thromboembolism (VTE) is a potential complication in children, adolescents, and young adults with cancer and other hematologic diagnoses. Conditions associated with hypercoagulation include sepsis, immobility, the presence of central venous catheters (CVCs), and malignancy.1 Pediatric and adolescent/young adult (AYA) hematology oncology patients often have many, if not all, of these risk factors. In addition, certain chemotherapeutic agents such as corticosteroids, asparaginase, and vincristine, all of which are used in the treatment for acute lymphoblastic leukemia, may predispose a patient to a VTE.1 In pediatric oncology patients, the overall incidence of symptomatic and asymptomatic VTE is 2.1% to 16% and 40%, respectively.2 A VTE can increase the hospital stay by 7 to 11 days and cost by an additional $1784 extra per day.3 To date, no widely accepted method exists to evaluate pediatric and AYA hematology oncology patients for the
Received for publication August 7, 2014; accepted May 23, 2015. From the *School of Nursing, Duke University, Durham, NC; wDepartment of Pediatrics; and zPopulation Sciences, City of Hope, Duarte, CA. A.D.B. was supported by a Graduate Scholarship in Cancer Nursing Practice from the American Cancer Society. The authors declare no conflict of interest. Reprints: Alison D. Bell, DNP, Department of Pediatrics, City of Hope, 1500 E Duarte Rd., Duarte, CA 91010 (e-mail: albell@ coh.org). Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
risk of VTE and the need for prophylaxis. At our 185-bed, not-for-profit, National Cancer Institute-designated comprehensive cancer center, adult patients admitted to the hospital are placed on VTE prophylaxis as recommended by the National Comprehensive Cancer Network (NCCN).4 However, no guidelines for VTE risk assessment and prophylaxis are currently used for the pediatric and AYA population. The use of a VTE risk-assessment tool and standardized guidelines for prophylaxis could increase the use of appropriate prophylaxis and reduce the number of VTEs in our pediatric and AYA hematology oncology patients, thereby decreasing morbidity, mortality, hospitalization, and cost.
LITERATURE REVIEW The use of a VTE risk-assessment tool is an effective way to identify patients who are at-risk for a VTE. Prentiss evaluated the reliability and validity of an assessment tool through a retrospective chart review of pediatric patients from birth to 20 years of age admitted to the hospital.5 A significant relationship between the risk score assigned and the incidence of VTE was identified (P < 0.001). The use of a risk-assessment tool for VTE increases the rate of appropriate prophylaxis and decreases the incidence of VTEs among pediatric hospitalized patients and has potential to do the same in pediatric hematology oncology patients. In hospitalized pediatric patients, Raffini et al6 implemented guidelines to assess VTE risk and prescribe appropriate thromboprophylaxis. They found that the rate of VTE prophylaxis in patients meeting criteria increased from a baseline average of 22% to an average rate of 82% over a 4-year study period. In addition, thromboprophylaxis use significantly increased over time (P < 0.001). Hanson et al7 implemented VTE prophylaxis guidelines in pediatric trauma patients (N = 546). They found no difference in the use of prophylaxis in the high-risk patients between the preimplementation, implementation, and postimplementation groups (P > 0.05). However, they did find a decrease in the incidence of total VTE (P = 0.041) and clinical VTE (P = 0.001) after the implementation of the guidelines.7 The use of a risk-assessment tool can identify patients who are at high as well as low risk for VTE. Hanson et al7 found that the use of VTE risk and prophylaxis guidelines among children admitted to the intensive care unit (ICU) after trauma had 2 important benefits: guideline use did not increase the use of prophylactic anticoagulation and anticoagulation use decreased in those who were at low risk (P = 0.03). Correctly identifying those who are at low risk
1 Copyright r 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. J Pediatr Hematol Oncol
Volume 00, Number 00, ’’ 2015
www.jpho-online.com |
J Pediatr Hematol Oncol
Bell et al
can prevent the unnecessary use of anticoagulation and the risk for its associated adverse effects. The purpose of this project was to implement an evidence-based VTE screening tool for pediatric oncology and hematology patients at our institution. Specific aims of this project were to (1) evaluate compliance with the use of the VTE risk-assessment tool for patients admitted to the pediatric hematology oncology service; and to (2) evaluate whether VTE prophylaxis or interventions—including referral to the pediatric hematologist, early ambulation, antiembolic hose, sequential compression device (SCD), and anticoagulation therapy—were initiated for patients found to be at-risk for VTE.
MATERIALS AND METHODS Setting, Sample, and Data Collection City of Hope is a 185-bed, not-for-profit, National Cancer Institute-designated comprehensive cancer center. Ages cared for in pediatrics range from birth to 30 years and include oncology, hematology, stem cell transplant, and surgical patients. The sample for this study included all patients admitted to the hospital’s pediatric service for a period of 3 months. Beginning 1 month following implementation of the risk-assessment tool, all charts and assessment tools were audited for 3 months. The assessment tools were assessed for completion within 24 hours of admission and change in clinical status, accuracy of risk assignment, and the medical records were assessed for documented initiation of VTE prophylaxis or interventions in medium-risk and high-risk patients. Patient characteristics including sex, age, reason for admission, diagnosis, presence of a central line, and a history of thrombophilia were also abstracted from the medical record.
VTE Risk-Assessment Tool The Prentiss Pediatric VTE Risk Assessment Tool determines a risk score based on a variety of risk factors.5 The criteria used in the Prentiss Pediatric VTE Risk Assessment Tool are identical to those found in the adult VTE guidelines literature. The NCCN guidelines also identify malignancy, familial hypercoagulability, infection, renal disease, obesity, history of VTE, presence of a CVC, and the use of oral contraceptives as risk factors for adult oncology patients.4 Contraindications to anticoagulation therapy were added to the tool as a guide for providers completing the tool. These include intracranial bleed, solid organ injury, planned surgical intervention, or invasive procedure within the past or next 24 hours, heparin or pork allergy, high risk of severe bleeding, ongoing or uncontrolled bleeding, uncorrected coagulopathy, renal failure, acute stroke, and heparin-induced thrombocytopenia.6,7
Intervention The Prentiss Pediatric VTE Risk Assessment Tool along with a list of possible interventions and the contraindications to anticoagulation therapy were consolidated onto 1 form. This form was added to the admission packets for all pediatric patients and was to be completed by the attending physician, nurse practitioner, or physician assistant upon the patient’s admission to the pediatric service and with any change in status (eg, transfer to and from the ICU or postoperatively). After completion, the form was placed in a designated folder in the pediatric unit. It was
Volume 00, Number 00, ’’ 2015
recommended that patients found to have a medium-risk or high-risk score should be considered for prophylaxis or other interventions. Possible interventions were listed on the tool itself and included a hematology consult, early ambulation or an order for physical therapy, antiembolic hose, SCD, and anticoagulation therapy.5–7 No specific interventions were recommended for high-risk versus medium-risk patients. On the basis of the patient’s risk score, clinical status, and contraindications to anticoagulation therapy, the clinician was to then order the most appropriate intervention in the patient’s chart.
Statistical Analysis Descriptive statistics were used to evaluate the proportion of assessment tools completed within 24 hours of admission or change in acuity, proportion of assessments scored accurately, number of patients with high-risk (3) or medium-risk (2) scores, number of patients referred to the pediatric hematologist, documented contraindications to anticoagulation, and number of patients prescribed VTE prophylaxis or interventions including early ambulation, antiembolic hose, SCDs, and anticoagulation therapy.
RESULTS During the 12-week study period, a total of 107 patients were admitted to the pediatric service and an additional 7 patients had a change in acuity for a total of 114 patients requiring assessment or reassessment for VTE risk (Table 1). From these 114 patient records, a total of 91 VTE assessments were completed (80%). Of the VTE assessments completed, 87 were completed accurately (96%). From the patients with completed tools (N = 91), 22 (24%) patients were found to be at high risk, 3 (3%) were found to be at medium risk, 58 (64%) were found to be at low risk, and 8 (9%) were found to not be at risk. The majority of the at-risk patients were greater than 12 years of age. Eleven (50%) of the high-risk patients were between the ages of 12 and 18 years, whereas 8 (36%) were between 19 and 31 years. The remaining 3 (14%) high-risk patients were between 6 and 11 years. Two (67%) of the mediumrisk patients were between 19 and 31 years and 1 (33%) was between 12 and 18 years. From the 25 at-risk patients, 23 (92%) had a CVC, 15 (60%) were obese (body mass
TABLE 1. Patient Characteristics (N = 114)
n (%) Sex Male Female Age range (y) 0-5 6-11 12-18 19-31 Diagnosis Sarcoma Leukemia/lymphoma Solid tumors/nonsarcoma Hemophilia Aplastic anemia Hemoglobinopathies Brain tumor Other
52 (45.6) 62 (54.4) 22 16 37 39
(19.3) (14.0) (32.5) (34.2)
51 36 8 7 4 3 2 3
(44.7) (31.6) (7.0) (6.1) (3.5) (2.6) (1.8) (2.6)
2 | www.jpho-online.com Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright r 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Pediatr Hematol Oncol
Volume 00, Number 00, ’’ 2015
index > 29), 11 (44%) were immobile, 4 (16%) were admitted or transferred to the ICU for sepsis, 5 (20%) had a history of deep vein thrombosis, and 1 (4%) was admitted for orthopedic surgery. Nineteen of the 22 high-risk and one of the 3 medium-risk patient had VTE prophylaxis ordered, for a total of 80% of the at-risk patients. Twelve of the patients had early ambulation or physical therapy ordered, 8 patients were ordered SCDs, and 2 patients were placed on anticoagulation therapy. Contraindications to anticoagulation included surgery (N = 1), active bleeding (N = 3), high risk for bleeding (N = 3), and coagulopathy (N = 1) (Table 2).
DISCUSSION The purpose of this project was to implement and assess the compliance of a pediatric-specific VTE riskassessment tool in pediatric hematology oncology patients. From the 114 pediatric patients requiring assessment, 91 (80%) VTE assessments were completed and 87 (96%) were completed accurately. Although 80% compliance is adequate for initial implementation, there remains much room for improvement. The majority of the VTE assessments that were not completed occurred on weekends when oncall pediatricians were primarily responsible for the admission. Although information regarding this project was sent to the on-call physicians, many of them are only occasionally on service and may have not been aware or may have forgotten about the VTE risk-assessment tool. Further education and reminders may be useful for both the on-call and staff physicians to increase compliance and accurate completion, especially during the weekends. Studies suggest that adding a VTE risk-assessment tool and TABLE 2. Characteristics of At-Risk Patients (N = 25)
n (%) High (N = 22) Age range (y) 0-5 0 (0) 6-11 3 (14) 12-18 11 (50) 19-31 8 (36) Risk factors CVC 21 (96) Obesity 13 (59) Immobility 10 (46) Past VTE 5 (23) Sepsis 3 (14) Ortho surgery 1 (5) Interventions Ambulation 11 (50) SCD 8 (36) Anticoagulation 2 (9) Antiembolic hose 0 (0) Referral to 0 (0) hematologist Contraindications to anticoagulation Ongoing bleeding 3 (14) High risk for 2 (9) bleeding Surgery 1 (5) Coagulopathy 1 (5)
Medium (N = 3)
Total (N = 25)
0 0 1 2
(0) (0) (33) (67)
0 3 12 10
(0) (12) (48) (40)
2 2 1 0 1 0
(67) (67) (33) (0) (33) (0)
23 15 11 5 4 1
(92) (60) (44) (20) (16) (4)
1 0 0 0 0
(33) (0) (0) (0) (0)
12 8 2 0 0
(48) (32) (8) (0) (0)
1 (33) 1 (33)
4 (16) 3 (12)
0 (0) 0 (0)
1 (4) 1 (4)
CVC indicates central venous catheter; VTE, venous thromboembolism; SCD, sequential compression device.
Venous Thromboembolism Risk Assessment
prophylactic guidelines to order sets increases compliance.8,9 Adding this assessment tool to the electronic admission and transfer order sets in the future may continue to assist with improving compliance. During the study period primary care providers completed the tool. However, this tool could potentially be completed by registered nurses who could notify a provider of the need for prophylaxis in patients found to be at risk. During the study period, 80% of the at-risk patients were ordered VTE prophylaxis. As there is no standard guideline for VTE prophylaxis in pediatric patients, some hesitancy may exist in ordering prophylaxis, especially anticoagulation with medications such as enoxaparin. Further investigation is warranted to assess the reasons that prophylaxis is not ordered and the rationale behind the prophylaxis chosen. SCDs and compressions stockings in small pediatric sizes are not currently available at the City of Hope, which may have been a barrier in ordering prophylaxis. Furthermore, research is also needed on the interventions that are most appropriate and effective for pediatric hematology oncology patients. The ages and diagnoses in our pediatric program are unique. The majority of the patients admitted were aged between 12 and 31 years. Had these older pediatric and AYA patients been admitted to our adult service, they would have received a form of prophylaxis based on the NCCN guidelines regardless of a risk score. The VTE riskassessment tool used does not consider age a risk factor. As there is an increased incidence of VTE in patients older than 15 years, adding this as a risk factor to the tool may be valuable. Type of cancer and therapy (eg, asparaginase and corticosteroids) also place patients at increased risk for VTE. Therefore, these factors could also be added to a VTE risk-assessment tool to further identify at-risk patients. No widely accepted method exists to evaluate pediatric and AYA hematology oncology patients for the risk of VTE and the need for prophylaxis. The use of a VTE riskassessment tool in pediatric and AYA hematology oncology patients is a feasible way to assess patients for their risk of developing a VTE. The Prentiss VTE Risk Assessment Tool is a simple and straightforward tool that was previously validated on pediatric inpatients. Further research is needed to assess the validity of this tool among hospitalized pediatric hematology oncology patients. ACKNOWLEDGMENT The authors specially thank Andrea S. Prentiss, PhD for the use of her VTE risk-assessment tool. REFERENCES 1. Nowak-Gottl U, Kenet G, Mitchell L. Thrombosis in childhood acute lymphoblastic leukaemia: epidemiology, aetiology, diagnosis, prevention and treatment. Best Pract Res Clin Haematol. 2009;22:103–114. 2. Piovesan D, Attard C, Monagle P, et al. Epidemiology of venous thromboembolsim in children with cancer. Thromb Haemost. 2014;111:1015–1021. 3. Etling LS, Escalante CP, Cooksley C, et al. Outcomes and cost of deep venous thrombosis among patients with cancer. Arch Intern Med. 2004;164:1653–1661. 4. National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: venous thromboembolic disease. 2013. Available at: http://www.nccn.org/professionals/physician_ gls/f_guidelines.asp#supportive. Accessed June 6, 2013.
3 Copyright r 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
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Bell et al
5. Prentiss A. Early recognition of pediatric venous thromboembolism: a risk assessment tool. Pediatr Crit Care. 2012;21:178–183. 6. Raffini L, Trimarchi T, Beliveau J, et al. Thromboprophylaxis in a pediatric hospital: a patient-safety and quality improvement initiative. Pediatrics. 2011;127:1326–1332. 7. Hanson S, Punzalan R, Arca M, et al. Effectiveness of clinical guidelines for deep vein thrombosis prophylaxis in reducing the incidence of venous thromboembolism in critically ill children after trauma. J Trauma. 2012;72:1292–1297.
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8. Haut E, Lau B, Kraenzlin F, et al. Improved prophylaxis and decreased rates of preventable harm with the use of a mandatory computerized clinical decisions support tool for prophylaxis for venous thromboembolism in trauma. Arch Surg. 2012;147: 901–907. 9. Maynard G, Morris T, Jenkins I, et al. Optimizing prevention of hospital-acquired venous thromboembolism (VTE): prospective validation of a VTE risk assessment model. J Hosp Med. 2010; 5:10–18.
4 | www.jpho-online.com Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright r 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Venous Thromboembolism Risk Assessment and Prophylaxis Use in Pediatric, Adolescent, and Young Adult Hematology Oncology Patients Alison D. Bell, DNP,*w Marilyn Hockenberry, PhD,* Wendy Landier, PhD,z and Nadia Ewing, MDw
Summary: No widely accepted method exists to evaluate pediatric hematology oncology patients for the risk of venous thromboembolism (VTE) and the need for prophylaxis. The use of a VTE risk-assessment tool and standardized guidelines for prophylaxis could increase the use of appropriate prophylaxis and reduce the number of VTEs in patients, thereby decreasing morbidity, mortality, hospitalization, and cost. The purpose of this project was to implement and assess the compliance of a pediatric-specific VTE risk-assessment tool in hospitalized pediatric, adolescent, and young adult hematology oncology patients. From the 114 pediatric, adolescent, and young adult patients requiring assessment, 91 (80%) VTE assessments were completed and 87 (96%) were completed accurately. Eighty percent of the at-risk patients were ordered VTE prophylaxis. The use of a VTE risk-assessment tool in pediatric hematology oncology patients is a feasible way to assess patients for their risk of developing a VTE. Key Words: thrombosis, pediatric oncology, risk assessment, screening
(J Pediatr Hematol Oncol 2015;00:000–000)
T
he development of a venous thromboembolism (VTE) is a potential complication in children, adolescents, and young adults with cancer and other hematologic diagnoses. Conditions associated with hypercoagulation include sepsis, immobility, the presence of central venous catheters (CVCs), and malignancy.1 Pediatric and adolescent/young adult (AYA) hematology oncology patients often have many, if not all, of these risk factors. In addition, certain chemotherapeutic agents such as corticosteroids, asparaginase, and vincristine, all of which are used in the treatment for acute lymphoblastic leukemia, may predispose a patient to a VTE.1 In pediatric oncology patients, the overall incidence of symptomatic and asymptomatic VTE is 2.1% to 16% and 40%, respectively.2 A VTE can increase the hospital stay by 7 to 11 days and cost by an additional $1784 extra per day.3 To date, no widely accepted method exists to evaluate pediatric and AYA hematology oncology patients for the
Received for publication August 7, 2014; accepted May 23, 2015. From the *School of Nursing, Duke University, Durham, NC; wDepartment of Pediatrics; and zPopulation Sciences, City of Hope, Duarte, CA. A.D.B. was supported by a Graduate Scholarship in Cancer Nursing Practice from the American Cancer Society. The authors declare no conflict of interest. Reprints: Alison D. Bell, DNP, Department of Pediatrics, City of Hope, 1500 E Duarte Rd., Duarte, CA 91010 (e-mail: albell@ coh.org). Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
risk of VTE and the need for prophylaxis. At our 185-bed, not-for-profit, National Cancer Institute-designated comprehensive cancer center, adult patients admitted to the hospital are placed on VTE prophylaxis as recommended by the National Comprehensive Cancer Network (NCCN).4 However, no guidelines for VTE risk assessment and prophylaxis are currently used for the pediatric and AYA population. The use of a VTE risk-assessment tool and standardized guidelines for prophylaxis could increase the use of appropriate prophylaxis and reduce the number of VTEs in our pediatric and AYA hematology oncology patients, thereby decreasing morbidity, mortality, hospitalization, and cost.
LITERATURE REVIEW The use of a VTE risk-assessment tool is an effective way to identify patients who are at-risk for a VTE. Prentiss evaluated the reliability and validity of an assessment tool through a retrospective chart review of pediatric patients from birth to 20 years of age admitted to the hospital.5 A significant relationship between the risk score assigned and the incidence of VTE was identified (P < 0.001). The use of a risk-assessment tool for VTE increases the rate of appropriate prophylaxis and decreases the incidence of VTEs among pediatric hospitalized patients and has potential to do the same in pediatric hematology oncology patients. In hospitalized pediatric patients, Raffini et al6 implemented guidelines to assess VTE risk and prescribe appropriate thromboprophylaxis. They found that the rate of VTE prophylaxis in patients meeting criteria increased from a baseline average of 22% to an average rate of 82% over a 4-year study period. In addition, thromboprophylaxis use significantly increased over time (P < 0.001). Hanson et al7 implemented VTE prophylaxis guidelines in pediatric trauma patients (N = 546). They found no difference in the use of prophylaxis in the high-risk patients between the preimplementation, implementation, and postimplementation groups (P > 0.05). However, they did find a decrease in the incidence of total VTE (P = 0.041) and clinical VTE (P = 0.001) after the implementation of the guidelines.7 The use of a risk-assessment tool can identify patients who are at high as well as low risk for VTE. Hanson et al7 found that the use of VTE risk and prophylaxis guidelines among children admitted to the intensive care unit (ICU) after trauma had 2 important benefits: guideline use did not increase the use of prophylactic anticoagulation and anticoagulation use decreased in those who were at low risk (P = 0.03). Correctly identifying those who are at low risk
1 Copyright r 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. J Pediatr Hematol Oncol
Volume 00, Number 00, ’’ 2015
www.jpho-online.com |
J Pediatr Hematol Oncol
Bell et al
can prevent the unnecessary use of anticoagulation and the risk for its associated adverse effects. The purpose of this project was to implement an evidence-based VTE screening tool for pediatric oncology and hematology patients at our institution. Specific aims of this project were to (1) evaluate compliance with the use of the VTE risk-assessment tool for patients admitted to the pediatric hematology oncology service; and to (2) evaluate whether VTE prophylaxis or interventions—including referral to the pediatric hematologist, early ambulation, antiembolic hose, sequential compression device (SCD), and anticoagulation therapy—were initiated for patients found to be at-risk for VTE.
MATERIALS AND METHODS Setting, Sample, and Data Collection City of Hope is a 185-bed, not-for-profit, National Cancer Institute-designated comprehensive cancer center. Ages cared for in pediatrics range from birth to 30 years and include oncology, hematology, stem cell transplant, and surgical patients. The sample for this study included all patients admitted to the hospital’s pediatric service for a period of 3 months. Beginning 1 month following implementation of the risk-assessment tool, all charts and assessment tools were audited for 3 months. The assessment tools were assessed for completion within 24 hours of admission and change in clinical status, accuracy of risk assignment, and the medical records were assessed for documented initiation of VTE prophylaxis or interventions in medium-risk and high-risk patients. Patient characteristics including sex, age, reason for admission, diagnosis, presence of a central line, and a history of thrombophilia were also abstracted from the medical record.
VTE Risk-Assessment Tool The Prentiss Pediatric VTE Risk Assessment Tool determines a risk score based on a variety of risk factors.5 The criteria used in the Prentiss Pediatric VTE Risk Assessment Tool are identical to those found in the adult VTE guidelines literature. The NCCN guidelines also identify malignancy, familial hypercoagulability, infection, renal disease, obesity, history of VTE, presence of a CVC, and the use of oral contraceptives as risk factors for adult oncology patients.4 Contraindications to anticoagulation therapy were added to the tool as a guide for providers completing the tool. These include intracranial bleed, solid organ injury, planned surgical intervention, or invasive procedure within the past or next 24 hours, heparin or pork allergy, high risk of severe bleeding, ongoing or uncontrolled bleeding, uncorrected coagulopathy, renal failure, acute stroke, and heparin-induced thrombocytopenia.6,7
Intervention The Prentiss Pediatric VTE Risk Assessment Tool along with a list of possible interventions and the contraindications to anticoagulation therapy were consolidated onto 1 form. This form was added to the admission packets for all pediatric patients and was to be completed by the attending physician, nurse practitioner, or physician assistant upon the patient’s admission to the pediatric service and with any change in status (eg, transfer to and from the ICU or postoperatively). After completion, the form was placed in a designated folder in the pediatric unit. It was
Volume 00, Number 00, ’’ 2015
recommended that patients found to have a medium-risk or high-risk score should be considered for prophylaxis or other interventions. Possible interventions were listed on the tool itself and included a hematology consult, early ambulation or an order for physical therapy, antiembolic hose, SCD, and anticoagulation therapy.5–7 No specific interventions were recommended for high-risk versus medium-risk patients. On the basis of the patient’s risk score, clinical status, and contraindications to anticoagulation therapy, the clinician was to then order the most appropriate intervention in the patient’s chart.
Statistical Analysis Descriptive statistics were used to evaluate the proportion of assessment tools completed within 24 hours of admission or change in acuity, proportion of assessments scored accurately, number of patients with high-risk (3) or medium-risk (2) scores, number of patients referred to the pediatric hematologist, documented contraindications to anticoagulation, and number of patients prescribed VTE prophylaxis or interventions including early ambulation, antiembolic hose, SCDs, and anticoagulation therapy.
RESULTS During the 12-week study period, a total of 107 patients were admitted to the pediatric service and an additional 7 patients had a change in acuity for a total of 114 patients requiring assessment or reassessment for VTE risk (Table 1). From these 114 patient records, a total of 91 VTE assessments were completed (80%). Of the VTE assessments completed, 87 were completed accurately (96%). From the patients with completed tools (N = 91), 22 (24%) patients were found to be at high risk, 3 (3%) were found to be at medium risk, 58 (64%) were found to be at low risk, and 8 (9%) were found to not be at risk. The majority of the at-risk patients were greater than 12 years of age. Eleven (50%) of the high-risk patients were between the ages of 12 and 18 years, whereas 8 (36%) were between 19 and 31 years. The remaining 3 (14%) high-risk patients were between 6 and 11 years. Two (67%) of the mediumrisk patients were between 19 and 31 years and 1 (33%) was between 12 and 18 years. From the 25 at-risk patients, 23 (92%) had a CVC, 15 (60%) were obese (body mass
TABLE 1. Patient Characteristics (N = 114)
n (%) Sex Male Female Age range (y) 0-5 6-11 12-18 19-31 Diagnosis Sarcoma Leukemia/lymphoma Solid tumors/nonsarcoma Hemophilia Aplastic anemia Hemoglobinopathies Brain tumor Other
52 (45.6) 62 (54.4) 22 16 37 39
(19.3) (14.0) (32.5) (34.2)
51 36 8 7 4 3 2 3
(44.7) (31.6) (7.0) (6.1) (3.5) (2.6) (1.8) (2.6)
2 | www.jpho-online.com Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright r 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Pediatr Hematol Oncol
Volume 00, Number 00, ’’ 2015
index > 29), 11 (44%) were immobile, 4 (16%) were admitted or transferred to the ICU for sepsis, 5 (20%) had a history of deep vein thrombosis, and 1 (4%) was admitted for orthopedic surgery. Nineteen of the 22 high-risk and one of the 3 medium-risk patient had VTE prophylaxis ordered, for a total of 80% of the at-risk patients. Twelve of the patients had early ambulation or physical therapy ordered, 8 patients were ordered SCDs, and 2 patients were placed on anticoagulation therapy. Contraindications to anticoagulation included surgery (N = 1), active bleeding (N = 3), high risk for bleeding (N = 3), and coagulopathy (N = 1) (Table 2).
DISCUSSION The purpose of this project was to implement and assess the compliance of a pediatric-specific VTE riskassessment tool in pediatric hematology oncology patients. From the 114 pediatric patients requiring assessment, 91 (80%) VTE assessments were completed and 87 (96%) were completed accurately. Although 80% compliance is adequate for initial implementation, there remains much room for improvement. The majority of the VTE assessments that were not completed occurred on weekends when oncall pediatricians were primarily responsible for the admission. Although information regarding this project was sent to the on-call physicians, many of them are only occasionally on service and may have not been aware or may have forgotten about the VTE risk-assessment tool. Further education and reminders may be useful for both the on-call and staff physicians to increase compliance and accurate completion, especially during the weekends. Studies suggest that adding a VTE risk-assessment tool and TABLE 2. Characteristics of At-Risk Patients (N = 25)
n (%) High (N = 22) Age range (y) 0-5 0 (0) 6-11 3 (14) 12-18 11 (50) 19-31 8 (36) Risk factors CVC 21 (96) Obesity 13 (59) Immobility 10 (46) Past VTE 5 (23) Sepsis 3 (14) Ortho surgery 1 (5) Interventions Ambulation 11 (50) SCD 8 (36) Anticoagulation 2 (9) Antiembolic hose 0 (0) Referral to 0 (0) hematologist Contraindications to anticoagulation Ongoing bleeding 3 (14) High risk for 2 (9) bleeding Surgery 1 (5) Coagulopathy 1 (5)
Medium (N = 3)
Total (N = 25)
0 0 1 2
(0) (0) (33) (67)
0 3 12 10
(0) (12) (48) (40)
2 2 1 0 1 0
(67) (67) (33) (0) (33) (0)
23 15 11 5 4 1
(92) (60) (44) (20) (16) (4)
1 0 0 0 0
(33) (0) (0) (0) (0)
12 8 2 0 0
(48) (32) (8) (0) (0)
1 (33) 1 (33)
4 (16) 3 (12)
0 (0) 0 (0)
1 (4) 1 (4)
CVC indicates central venous catheter; VTE, venous thromboembolism; SCD, sequential compression device.
Venous Thromboembolism Risk Assessment
prophylactic guidelines to order sets increases compliance.8,9 Adding this assessment tool to the electronic admission and transfer order sets in the future may continue to assist with improving compliance. During the study period primary care providers completed the tool. However, this tool could potentially be completed by registered nurses who could notify a provider of the need for prophylaxis in patients found to be at risk. During the study period, 80% of the at-risk patients were ordered VTE prophylaxis. As there is no standard guideline for VTE prophylaxis in pediatric patients, some hesitancy may exist in ordering prophylaxis, especially anticoagulation with medications such as enoxaparin. Further investigation is warranted to assess the reasons that prophylaxis is not ordered and the rationale behind the prophylaxis chosen. SCDs and compressions stockings in small pediatric sizes are not currently available at the City of Hope, which may have been a barrier in ordering prophylaxis. Furthermore, research is also needed on the interventions that are most appropriate and effective for pediatric hematology oncology patients. The ages and diagnoses in our pediatric program are unique. The majority of the patients admitted were aged between 12 and 31 years. Had these older pediatric and AYA patients been admitted to our adult service, they would have received a form of prophylaxis based on the NCCN guidelines regardless of a risk score. The VTE riskassessment tool used does not consider age a risk factor. As there is an increased incidence of VTE in patients older than 15 years, adding this as a risk factor to the tool may be valuable. Type of cancer and therapy (eg, asparaginase and corticosteroids) also place patients at increased risk for VTE. Therefore, these factors could also be added to a VTE risk-assessment tool to further identify at-risk patients. No widely accepted method exists to evaluate pediatric and AYA hematology oncology patients for the risk of VTE and the need for prophylaxis. The use of a VTE riskassessment tool in pediatric and AYA hematology oncology patients is a feasible way to assess patients for their risk of developing a VTE. The Prentiss VTE Risk Assessment Tool is a simple and straightforward tool that was previously validated on pediatric inpatients. Further research is needed to assess the validity of this tool among hospitalized pediatric hematology oncology patients. ACKNOWLEDGMENT The authors specially thank Andrea S. Prentiss, PhD for the use of her VTE risk-assessment tool. REFERENCES 1. Nowak-Gottl U, Kenet G, Mitchell L. Thrombosis in childhood acute lymphoblastic leukaemia: epidemiology, aetiology, diagnosis, prevention and treatment. Best Pract Res Clin Haematol. 2009;22:103–114. 2. Piovesan D, Attard C, Monagle P, et al. Epidemiology of venous thromboembolsim in children with cancer. Thromb Haemost. 2014;111:1015–1021. 3. Etling LS, Escalante CP, Cooksley C, et al. Outcomes and cost of deep venous thrombosis among patients with cancer. Arch Intern Med. 2004;164:1653–1661. 4. National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: venous thromboembolic disease. 2013. Available at: http://www.nccn.org/professionals/physician_ gls/f_guidelines.asp#supportive. Accessed June 6, 2013.
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5. Prentiss A. Early recognition of pediatric venous thromboembolism: a risk assessment tool. Pediatr Crit Care. 2012;21:178–183. 6. Raffini L, Trimarchi T, Beliveau J, et al. Thromboprophylaxis in a pediatric hospital: a patient-safety and quality improvement initiative. Pediatrics. 2011;127:1326–1332. 7. Hanson S, Punzalan R, Arca M, et al. Effectiveness of clinical guidelines for deep vein thrombosis prophylaxis in reducing the incidence of venous thromboembolism in critically ill children after trauma. J Trauma. 2012;72:1292–1297.
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8. Haut E, Lau B, Kraenzlin F, et al. Improved prophylaxis and decreased rates of preventable harm with the use of a mandatory computerized clinical decisions support tool for prophylaxis for venous thromboembolism in trauma. Arch Surg. 2012;147: 901–907. 9. Maynard G, Morris T, Jenkins I, et al. Optimizing prevention of hospital-acquired venous thromboembolism (VTE): prospective validation of a VTE risk assessment model. J Hosp Med. 2010; 5:10–18.
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