Venous thromboembolism prophylaxis practice and its association with outcomes in Australia and New Zealand burns patients

Abstract

Background: Patients with burn injuries are considered to have an increased risk of venous thromboembolism (VTE). While untreated VTEs can be fatal, no studies have examined chemoprophylaxis effectiveness. This study aimed to quantify the variation in prevalence of VTE prophylaxis use in patients in Australian and New Zealand burns units and whether prophylaxis use is associated with in-hospital outcomes following burn injury. Methods: Admission data for adult burns patients (aged ≥16 years) admitted between 1 July 2016 and 31 December 2018 were extracted from the Burns Registry of Australia and New Zealand. Mixed effects logistic regression modelling investigated whether VTE prophylaxis use was associated with the primary outcome of in-hospital mortality. Results: There were 5066 admissions over the study period. Of these patients, 81% (n = 3799) with a valid response to the VTE prophylaxis data field received some form of VTE prophylaxis. Use of VTE prophylaxis ranged from 48.6% to 94.8% of patients between units. In-hospital death was recorded in <1% of patients (n = 33). After adjusting for confounders, receiving VTE prophylaxis was associated with a decrease in the adjusted odds of in-hospital mortality (adjusted odds ratio = 0.21; 95% CI, 0.07–0.63; p = 0.006). Conclusions: Variation in the use of VTE prophylaxis was observed between the units, and prophylaxis use was associated with a decrease in the odds of mortality. These findings provide an opportunity to engage with units to further explore differences in prophylaxis use and develop future best practice guidelines.

Keywords

Burn injury / Venous thromboembolism / Prophylaxis / Australia / New Zealand

References

[1] Abedi N, Papp A. A survey of current practice patterns in prophylaxis against venous thromboembolism (VTE) and gastrointestinal (GI) ulceration among Canadian burn centers. Burns. 2011; 37: 1182-6.

[2] Pannucci CJ, Obi AT, Timmins BH, Cochran AL. Venous thromboembolism in patients with thermal injury: a review of risk assessment tools and current knowledge on the effectiveness and risks of mechanical and chemical prophylaxis. Clin Plast Surg. 2017; 44: 573-81.

[3] Barret JP, Dziewulski PG. Complications of the hypercoagulable status in burn injury. Burns. 2006; 32: 1005-8.

[4] Harrington DT, Mozingo DW, Cancio L, Bird P, Jordan B, Goodwin CW. Thermally injured patients are at significant risk for thromboembolic complications. J Trauma. 2001; 50: 495-9.

[5] MacDougall DA, Feliu AL, Boccuzzi SJ, Lin J. Economic burden of deep-vein thrombosis, pulmonary embolism, and post-thrombotic syndrome. Am J Health Syst Pharm. 2006; 63: S5-15.

[6] Access Economics. The burden of venous thromboembolism in Australia, 2008. Available online via https://www.safetyandquality.gov.au/publications-and-resources/resource-library/burden-venous-thromboembolism-australia.

[7] Pannucci CJ, Osborne NH, Wahl WL. Venous thromboembolism in thermally injured patients: analysis of the National Burn Repository. J Burn Care Res. 2011; 32: 6-12.

[8] Fecher AM, O’Mara MS, Goldfarb IW, Slater H, Garvin R, Birdas TJ, et al. Analysis of deep vein thrombosis in burn patients. Burns. 2004; 30: 591-3.

[9] Ahuja RB, Bansal P, Pradhan GS, Subberwal M. An analysis of deep vein thrombosis in burn patients (part 1): comparison of D-dimer and Doppler ultrasound as screening tools. Burns. 2016; 42: 1686-92.

[10] Thromboembolic Risk Factors (THRIFT) Consensus Group.Risk of and prophylaxis for venous thromboembolism in hospital patients. BMJ. 1992; 305: 567-74.

[11] White RH, Gettner S, Newman JM, Trauner KB, Romano PS. Predictors of rehospitalization for symptomatic venous thromboembolism after total hip arthroplasty. N Engl J Med. 2000; 343: 1758-64.

[12] Hull RD, Raskob GE, Hirsh J. Prophylaxis of venous thromboembolism. An overview. Chest. 1986; 89: 374S-83S.

[13] Tran HA, Gibbs H, Merriman E, Curnow JL, Young L, Bennett A, et al. New guidelines from the thrombosis and haemostasis Society of Australia and new Zealand for the diagnosis and management of venous thromboembolism. Med J Aust. 2019; 210: 227-35.

[14] Oremus M, Hanson MD, Whitlock R, Young E, Archer C, Dal Cin A, et al. A systematic review of heparin to treat burn injury. J Burn Care Res. 2007; 28: 794-804.

[15] Sikora S, Papp A. Venous thromboembolism in burn patients is not prevented by chemoprophylaxis. Burns. 2017; 43: 1330-4.

[16] Cleland H, Greenwood JE, Wood FM, Read DJ, Wong She R, Maitz P, et al. The burns registry of Australia and New Zealand: progressing the evidence base for burn care. Med J Aust. 2016; 204: 195- 195.

[17] McInnes JA, Cleland H, Tracy LM, Darton A, Wood FM, Perrett T, et al. Epidemiology of work-related burn injuries presenting to burn centres in Australia and New Zealand. Burns. 2019; 45: 484-93.

[18] McInnes JA, Cleland HJ, Cameron PA, Darton A, Tracy LM, Wood FM, et al. Epidemiology of burn-related fatalities in Australia and New Zealand, 2009-2015. Burns. 2019; 45: 1553-61.

[19] Tracy LM, Dyson K, Le Mercier L, Cleland H, McInnes JA, Cameron PA, et al. Variation in documented inhalation injury rates following burn injury in Australia and New Zealand. Injury. 2020; 51: 1152-7.

[20] Tracy LM, McInnes JA, Gong J, Gabbe BJ, Thomas T. Burns Registry of Australia and New Zealand 8th Annual Report. Technical report. Melbourne, Australia: Monash University, 2018. Available online via https://www.monash.edu/__data/assets/pdf_file/0005/1411349/BRANZ-8th-Annual-Report-Jul-16-Jun-17_0.pdf.

[21] Tracy LM, McInnes JA, Gong J, Karunakaran R, Gabbe BJ. Burns Registry of Australia and New Zealand 9th Annual Report. Technical report. Melbourne, Australia: Monash University, 2019. Available online via https://www.monash.edu/__data/assets/pdf_file/0003/1870005/BRANZ_AnnualReport_Year9_FINAL.pdf.

[22] Wood FM, Phillips M, Jovic T, Cassidy JT, Cameron P, Edgar DW. Water first aid is beneficial in humans post-burn: evidence from a bi-national cohort study. PLoS One. 2016; 11(1): e0147259.

[23] Chu C-C, Haga H. Venous thromboembolism associated with lower limb fractures after trauma: dilemma and management. J Orthop Sci. 2015; 20: 364-72.

[24] Kim DY, Kobayashi L, Barmparas G, Fortlage D, Curry T, Coimbra R. Venous thromboembolism in the elderly: the result of comorbid conditions or a consequence of injury? J Trauma Acute Care Surgery. 2012; 72: 1286-91.

[25] National Centre for Classification in Health. International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM), the Australian Classification of Health Interventions (ACHI) and the Australian Coding Standards (ACS), Darlinghurst, Sydney: University of Sydney, 2010.

[26] Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987; 40: 373-83.

[27] Spiegelhalter DJ. Funnel plots for comparing institutional performance. Stat Med. 2005; 24: 1185-202.

[28] Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arceuls JI, Heit JA, et al. Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141: 227S-77S.

[29] Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuune-mann HJ. Executive summary: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141: 7S-47S.

[30] Latenser BA, Miller SF, Bessey PQ, Browning SM, Caruso DM, Gomez M, et al. National Burn Repository 2006: a ten-year review. J Burn Care Res. 2007; 28: 635-58.

[31] Miller SF, Bessey PQ, Schurr MJ, Browning SM, Jeng JC, Caruso DM, et al. National Burn Repository 2005: a ten-year review. J Burn Care Res. 2006; 27: 411-36.

[32] Rue LW III, Cioffi WG Jr, Rush R, McManus WF, Pruitt BA Jr. Thromboembolic complications in thermally injured patients. World J Surg. 1992; 16: 1151-4.