Venous Thromboembolism Chemoprophylaxis in Traumatic Intracranial Hemorrhage

Venous thromboembolism (VTE) includes deep vein thrombosis and pulmonary embolism. It is a common complication of neurosurgical patients with an incidence in traumatic brain injury as high as 54%. Understanding that this is a preventable complication, one can recognize this statistic as alarming. Anticoagulants are widely utilized to prevent VTE. However, patients who have suffered a traumatic intracranial hemorrhage are already at risk for bleeding. It is difficult to determine when it is safe to use pharmacologic prophylaxis without causing progression of the hemorrhage or a new one from occurring. Currently, there is no standard of care regarding the initiation of VTE chemoprophylaxis. Most research studies about VTE prophylaxis exclude patients with traumatic intracranial hemorrhage. Decisions about when to initiate VTE chemoprophylaxis in this patient population are made by individual providers on a case-by-case basis. They rely heavily on past experience and intuition and VTE chemoprophylaxis is initiated when they feel most comfortable. This results in inconsistency among providers. Due to the difficulty in ascertaining the risks and benefits of starting VTE chemoprophylaxis in these patients, many providers regularly face dilemmas on how to best treat their patients. The purpose of this study was to decrease provider dilemma regarding when to initiate VTE chemoprophylaxis in patients with traumatic intracranial hemorrhage. The objectives were to identify an algorithm providing evidence-based recommendations about when to initiate VTE chemoprophylaxis, incorporate the algorithm into practice, determine the effectiveness of the algorithm, and disseminate the findings. A comprehensive literature review was conducted and an appropriate algorithm was identified. IRB approval was obtained. A pre-implementation questionnaire was distributed to the neurosurgery service at a level one-trauma center, including neurosurgeons and advanced practice clinicians. It helped to determine current practice with VTE chemoprophylaxis. The pre-identified algorithm was presented to the neurosurgery service for feedback and buy-in. The algorithm was then incorporated into practice. A post-implementation questionnaire was distributed to determine whether or not it decreased provider dilemma. An algorithm evaluation questionnaire was also circulated to determine its effectiveness. Ten of twelve pre-implementation questionnaires were returned. Nine of twelve post-implementation questionnaires were returned. Pre-algorithm, six respondents stated this dilemma was faced ‘often' and three ‘always'; post-algorithm, four stated ‘often' and four stated ‘always'. Participants reported that they base their decisions of whether or not to start VTE chemoprophylaxis on ‘size', ‘type', ‘location' of hemorrhage, and ‘patient comorbidities'. Additionally, ‘past experience', ‘intuition/clinical judgment', and ‘literature' have been influential. Two respondents added the new algorithm as something on which they base their decisions. It was unanimously agreed both pre- and post-algorithm that a standardized algorithm would decrease provider dilemma. Seven of nine respondents found the algorithm ‘very useful' with eight saying it decreased dilemmas and six saying they were ‘very likely' to use it again. As the clinical results of the algorithm were not a part of this project, this project could be expanded. Further research is necessary to determine patient outcomes.