This document discusses venous thromboembolism (VTE) risk assessment models used at Sultan Bin Abdulaziz Humanitarian City. It reviewed several risk assessment models and ultimately adopted a hybrid approach using the Padua prediction score for medical patients and the Caprini assessment tool for surgical patients. The policy requires all adult patients to be assessed for VTE risk upon admission, changes in status, transfers between care levels, and discharge. Reassessments are also required if new risk factors emerge.

1. VTE RISK ASSESSMENT MODELS
Sultan Bin Abdul Aziz Humanitarian City experience
Dr Omer S. Khan
Chief Medical Resident, SBAHC

2. VTE PREVENTION POLICY
 To standardize and provide evidence based risk
assessment for thromboembolism and appropriate
intervention for medical and surgical patients
admitted to Sultan Bin Abdulaziz Humanitarian City.

3. POLICY
All hospitalized medical, and surgical adult patients will
be assessed and prescribed the most appropriate
intervention by the treating physician for VTE risk
 At the time of admission to hospital
 At the time of significant change in clinical status
 At the time of transfer from one type (level) of care to
another
 At discharge

4. INCLUSION AND EXCLUSION CRITERIA
Inclusion: All adult patients admitted to SBAHC will
be screened for VTE risk
Exclusion: ER patients
(Review based on clinical judgment)
Outpatient Clinic
(Review based on clinical judgment)
Paediatrics……..?

5. SCOPE OF GUIDELINES
Our guidelines provides supportive documentation for
the Sultan Bin Abdulaziz Humanitarian City VTE
prophylaxis for the hospitalized patients.
 Practice based on the best evidence (9thed: ACCP
Evidence-Based Clinical Practice Guidelines on
February 23, 2012)

6. SCOPE OF GUIDELINES
 Rationale for thromboprophylaxis
recommendations
 Approaches to be used for VTE
risk assessment
 Bleeding risk assessment
 Guide on pharmacological and
non pharmacological prophylaxis
in different patient population
subsets
 Roles and responsibilities of
health care providers

7. SCOPE OF GUIDELINES
SBAHC unique patient population and scope
 Spinal cord injury
 Brain injury
 Amputees
 Stroke and recurrent stroke
Rehabilitated and mobility restored

8. RAM SELECTION
 Choice of Risk assessment models.
Which one to follow?
 Committee meetings
 Extensive literature review
 Discussions and deliberation

9. RAM SELECTION Questions and challenges
 VTE prophylaxis was suboptimal in SBAHC in
particular and in KSA hospitals in general despite
long-standing evidence-based recommendations
 Data from observational studies indicate a lower
uptake of effective prophylaxis in patients
hospitalized with medical versus surgical
conditions
Reluctance to use prophylaxis in medical patients
1. Identifying at-risk patients
2. Balancing risks of bleeding against occurrence of
VTE

10. RAM SELECTION Questions and challenges
 Several risk-assessment models (RAMs) have been
proposed to assist physicians in identifying surgical
and non-surgical patients who need prophylaxis
 Published RAMs lack
1. Generalizability
2. Adequate validation
 Validated dynamic RAMs are needed to assess VTE
risk at the point-of-care in real time

11. LITERATURE REVIEW
 Caprini risk assessment tool
 Padua prediction score
 Kucher
 IMPROVE prediction model
 IMPROVE Associative Score for VTE
 Intermountain
 Roger’s score
 NSW Health Clinical Pathway
 Goldhaber

12. LITERATURE REVIEW
 Surgical Patients Caprini risk
assessment tool
 Medical Patients
Caprini risk assessment tool
Vs
Padua prediction score

13. Comparison between Caprini and Padua
risk assessment models for hospitalized
medical patients at risk for venous
thromboembolism: a retrospective study
Xiaohan Liua, Chengyuan Liua,†, Xi Chena, Wenwen Wub and Gendi Lua,
Department of Nursing, Changzheng Hospital, Second Military Medical University, Shanghai, China , Department of
Cardiothoracic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
Received December 6, 2015. Revision received March 22, 2016. Accepted April 9, 2016.
OBJECTIVES
This study aimed to evaluate the validity of the risk assessment model
(RAM) of Caprini and Padua in identifying venous thromboembolism
(VTE) among hospitalized medical patients.
METHODS
 This retrospective study reviewed a total of 320 VTE and 320 non-
VTE patients
 The Caprini and Padua RAMs were implemented and the individual
scores of each risk factor were summed to generate a cumulative
risk score
 Sensitivity, specificity, and positive and negative predictive values of
these two models were analysed
 Receiver operating characteristic (ROC) curve was plotted to
calculate the area under the curve (AUC) and the Youden index.

14. RESULTS Significant differences were
observed in risk factors between VTE and
non-VTE patients
More VTE patients were classified into the
high–superhigh risk level by the Caprini RAM
than the Padua RAM (70.9 vs 23.4%, P <
0.01)
 The sensitivity and +ve and -ve predictive
values in the Caprini RAM > Padua RAM (P
< 0.05)
 Specificity of the Caprini < Padua RAM (P
< 0.01)
The AUC and the Youden index Caprini >
Padua RAM (P < 0.01)

15.  CONCLUSIONS
The Caprini RAM was suggested to be more effective
than the Padua RAM for identification of hospitalized
medical patients at risk for VTE

16. Validation of the Caprini Score for Risk
Assessment of Venous Thromboembolism
in Hospitalized Medical Patients
 P. Grant, MD; S. A. Flanders, MD; M. T. Greene, PhD; S. J. Bernstein, MD
 University of Michigan, Ann Arbor, MI
VA Ann Arbor Healthcare System, Ann Arbor, MI
 Meeting: SHM Annual Meeting 2014
 Although the Caprini RAM has been validated in
surgery patients, it was sought to determine its
predictive value for VTE events in hospitalized
medical patients.

17.  METHODS
Using web‐based data entry, a nurse abstractor at each
participating hospital (n=40) collected detailed
demographic and clinical data, including all known risk
factors for VTE and use of pharmacologic prophylaxis.
The occurrence of VTE events during hospitalization and
90‐day post‐discharge follow‐up were determined by
medical record review and follow‐up phone calls.
Non‐parametric test for trend across ordered groups and
logistic regression to determine if increasing Caprini
score values were associated with VTE events.
Caprini point scoring system was used to define low (0 ‐1
points), moderate (2‐4 points) and high (5+ points) risk
categories.

18.  RESULTS
Among the 52,989 patients included in this analysis,
299 (0.56%) had a VTE event by 90 days
Significant increase in VTE with incremental increases
in Caprini scores (p for trend <0.001)

19.  Compared to low risk patients, the odds of having a
VTE event was 3‐fold greater among high risk
patients (p=0.039).
However….
 The odds of VTE did not differ between the low and
moderate risk groups.

20.  Among patients with a Caprini score of 5 or greater,
the rate of VTE for patients on pharmacologic
prophylaxis (0.72%) did not differ from those not on
pharmacologic prophylaxis (0.86%), chi‐squared =
1.29, p = 0.26

21.  CONCLUSIONS
In a large cohort of hospitalized medical patients, an
increasing Caprini score was predictive of a greater
risk for VTE
The odds of developing VTE was only significant
among high risk patients, however, exposure to
pharmacologic prophylaxis did not affect the event
rate
Although the Caprini RAM appears to be a valid
predictor of VTE risk, it did not effectively
discriminate populations for which pharmacologic
prophylaxis was useful

23. Venous Thromboembolism Risk
Assessment Models for Hospitalized
Medical Patients
 M. T. Greene, PhD; S. Kaatz, DO; S. J. Bernstein, MD,; P. Grant, MD; J. N. Wietzke,
MHSA, MLS; S. A. Flanders, MD
University of Michigan, Ann Arbor, MI
Hurley Medical Center, Flint, MIVA Ann Arbor Healthcare System, Ann Arbor, MI
SHM Annual Meeting 2014
 The Michigan Hospital Medicine Safety Consortium
(HMS), a state‐based quality collaborative aimed at
preventing adverse events in hospitalized medical
patients, reviewed various RAMs in an effort to determine
which model(s) has the most utility for medical patients

24. METHODS
 Using web‐based data entry, hospitals collected demographic
and clinical data, including known risk factors, use of
pharmacologic prophylaxis, and VTE events through 90 days
after discharge for 760 patients annually
 VTE outcomes were determined by medical record review and
follow‐up phone calls and included all DVT and pulmonary
embolism events.
 The Intermountain, IMPROVE, Padua, Kucher, and Caprini
RAMs were applied to the HMS population and risk was
classified as “at risk” or “low risk” based on the respective
published cutpoints
 Backward stepwise logistic regression was used to develop a
simple HMS RAM
 To determine the predictive capabilities of the various RAMs,
VTE events were regressed against each RAM
 Respective model discrimination was assessed via the
c‐statistic

25.  RESULTS
The performance of each
of the RAMs was
assessed on data
collected on a total of
52,989 patients. In
general, model
discrimination was
poor, with c‐statistics
ranging from 0.51 –
0.65
A simple 3‐element RAM
yielded the best model
discrimination
(c‐statistic = 0.65).

27. CONCLUSION
 The ability to predict VTE risk among a large cohort
of hospitalized medical patients using existing and
developed RAMs was limited
 Parsimonious RAMs may have greater predictive
ability and have the added advantage of facilitating
risk assessment due to their simplicity.
 Additional work to determine which medical patients
are at greatest risk for VTE and require appropriate
thromboprophylaxis is warranted

28. FINAL CONSENSUS
 Hybrid approach

29. FINAL CONSENSUS
 Upon admission, the initial assessment will be done
within 24 hours of the patient admission time by the
physician, using Screening and Prophylaxis VTE Risk
Assessment tool
 PADUA prediction score model for medical patients
 Caprini assessment tool for surgical patients

30. PROCEDURE
 The treating team will order the VTE prophylaxis according to
the guideline recommendations.
 During the hospitalization the Nurse should do VTE
reassessment if new events occur such as infection, surgery,
fracture, transfer from level of care to another etc. then the
score should be updated.
 Any changes or fluctuation in the score, physician shall be
notified immediately.
 Upon discharge, the VTE assessment will be done by the
treating team and will order the VTE prophylaxis according to
the patients need, and guideline recommendations.
The physician may override the clinical guidelines based on
his clinical Judgment

31. The physician may override the clinical
guidelines based on his clinical judgment
 Where firm recommendations are available, the
physician should treat according to the evidence
 Where evidence is lacking, the physician should
assess each patient based on their medical and
clinical status and use a risk factor model to help
stratify patients according to risk
 Combining guidelines with intelligent clinical practice,
more patients should receive appropriate
prophylactic treatment tailored to their individual risk

36. MEASURES
 Percentage of staff compliance to implement VTE
risk assessment tool
 Interrater reliability test for the VTE risk assessment
tool
 Percentage of patients who receive VTE prophylaxis
following VTE clinical pathway
 Current VTE prophylaxis indicator for surgical
patients

37. SBAHC VTE PROPHYLAXIS PROJECT TEAM
 Abdulilah Fayyad
Clinical Resource Nurse
 Dr. Ahmer Waheed
Quality and Risk Management Specialist
 Dr. Elfateh Elkhatib
Consultant Internal Medicine
 Manar Sweiss
Clinical Pharmacist
 Dr. Omer Khan
Medical Resident
 Dr. Khazim Sakalla
Consultant Orthopedic Surgeon

38. Thank you