Hadley Bortz

The recent NEJM Evidence trial questioned the benefit of enoxaparin for venous thromboembolism (VTE) prevention among older hospitalised medical patients. We conducted a retrospective, observational audit of 142 elderly inpatients at a large Australian tertiary institution; most received enoxaparin unless contraindicated, with excellent adherence to guidelines. Clinical events were rare with two VTE (1.4%) and five minor bleeds (3.5%) recorded and no major bleeding observed. Approximately 10% of patients were ambulant and prescribed thromboprophylaxis outside guideline criteria, yet bleeding rates were low. Our findings suggest high guideline compliance and minimal bleeding associated with enoxaparin prophylaxis in this population. There is a need for simple and practical risk stratification tools with clear ambulation definitions, routine mobility assessments where appropriate and consideration of patient‐accepted approaches such as oral thromboprophylaxis options.

Patients with major burn injuries are at high risk of venous thromboembolism. In 2022, a new prophylaxis guideline was introduced for adults with burns ≥ 20% total body surface area: enoxaparin 40 mg twice daily, renally, and weight adjusted. This quality improvement study assessed compliance and outcomes by comparing patients admitted postguideline (January 2022–December 2023) to a preguideline cohort (July 2019–June 2021) who received enoxaparin 40 mg daily. Among 138 actively treated patients (77% male, median age 43 years, and median % total body surface area 35), 57 were treated preguideline and 45 post, with no major differences between groups. Preguideline, 5 patients developed venous thromboembolic complications (2 pulmonary emboli, 3 deep vein thromboses) versus 3 incidental thromboembolisms (1 pulmonary embolus, 2 deep vein thromboses) postguideline. Transfusion for bleeding was similar across groups, but major bleeding affecting dermal substitute application increased from 1 case (2%) preguideline to 7 cases (15%) postguideline, this difference was not statistically significant. To mitigate this, intravenous tranexamic acid and increased transfusion rates were implemented after 12 months, eliminating major bleeding events in the subsequent period. Overall, 88% of patients received venous thromboembolic prophylaxis in line with the guideline. Despite an initial increase in bleeding complications, intraoperative adjustments resolved these issues, demonstrating a learning curve. The guideline was successfully implemented and appears effective in reducing venous thromboembolic risk with acceptable complications.

Objectives: To assess adherence and persistence to the direct factor Xa inhibitor oral anticoagulants in the community following newly diagnosed venous thromboembolism (VTE). Methods: We retrospectively reviewed community pharmacy dispensing data on all patients with newly diagnosed VTE who were prescribed direct factor Xa inhibitors, apixaban or rivaroxaban, between January 2018 and December 2019 at our institution. Proportion of days covered (PDC) was used to assess adherence at 90 days, and 6- and 12 months. Persistence was measured by participants having both dispensed supply of a factor Xa inhibitor at the end of the treatment period and no significant gaps (maximum of 60 days) in supply. Key findings: There were 225 patients identified. Overall PDC at 90 days, 6- and 12 months were 84.6%, 86.2% and 86.1%, respectively. Apixaban had a higher mean overall PDC than rivaroxaban (86.2% and 80.6%, respectively). Females demonstrated higher PDC compared with males (87.3% versus 81.2%). Overall, 133 patients (64%) were persistent with therapy. Conclusions: In patients with newly diagnosed VTE treated with a factor Xa inhibitor, adherence rates are high at >80%, with females and those prescribed apixaban exhibiting higher adherence. These findings may assist clinicians in identifying those patients with VTE at risk of poor adherence.

Background: Use of intravascular warming catheters following major burns has been shown to be effective to maintain normothermia, but their use may be associated with complications. The aim of this study was to determine what proportion of patients with an intravascular warming catheter developed a potentially catheter-related venous thromboembolism (VTE) and to identify contributing risk factors. Methods: This was a retrospective cohort study of patients admitted to the Victorian Adult Burns Service January 2013 to July 2018 with major burns (TBSA > 20%) who had an ICY^TM intravascular warming catheter. Warming catheter insertion and other details were identified with a manual search of the patients’ medical records by a single author while incidence of VTE was determined by the coding department from a central database. Results: Forty patients had an intravascular warming catheter inserted during the study period. The number of patients in the catheter group that sustained a VTE was eight (20%), of which four (10%) could have been catheter-related due to the anatomical location. In the cases of the four potentially catheter-related VTE, other preventable VTE risk factors including suboptimal prophylactic anticoagulation (n = 2), prolonged catheter duration (n = 1) and prolonged haemoconcentration (n = 2) were identified. Conclusions: We found 20% of major burns patients with an intravascular warming device had significant VTE; however, only half of these may have been related to the catheter. A careful assessment for each patient that balances risks and benefits should be undertaken prior to using intravascular warming devices.

The Health Roundtable, a national benchmarking body, identified our institution as an outlier with a high number of postoperative venous thromboembolism (VTE) events. We performed a retrospective study to determine the accuracy of hospital coding for the incidence and severity of postoperative VTE. Of 232 patients identified from ICD-10 coding, 52 (22.4%) were incorrectly coded. Approximately one third (n =68) of all VTE were asymptomatic, diagnosed incidentally. Thus, coding data are inherently flawed with inaccuracy and overrepresent the true number of VTE events, with a substantial proportion of limited clinical relevance.