Heading Off Death

Life-threatening blood clots are a growing problem in hospitals.

Deep-vein thrombosis, or DVT, is commonly associated with long-haul air travel, where passengers are confined to cramped spaces for many hours. Vice Presidents Dan Quayle and Dick Cheney have both suffered DVT linked to air travel.

But the biggest danger is to hospitalized patients, where DVT followed by pulmonary embolism — a sequence of occurrences known as a venous thromboembolism event, or VTE — kills nearly 200,000 U.S. patients a year. Though VTE most often happens to adults over 40, any patient on bed rest after illness or surgery is vulnerable, even after being discharged from hospital. It is the leading cause of maternal death associated with childbirth, which puts pressure on deep veins.

Now, a growing number of hospitals are moving to do a better job of averting life-threatening clots. They are more carefully screening for potential risk factors including obesity, smoking and a family history of clotting problems. They also are more closely following established guidelines for prevention, such as putting certain patients on blood-thinning medications — including anticlotting drugs heparin or warfarin — and using special compression socks after surgery that improve circulation in the legs.

For the most part, however, hospitals and surgery centers often fail to screen patients for risks of DVT, and only about a third of patients receive the recommended prevention therapies, studies show.

Helping to pressure hospitals to do a better job to prevent blood clots is a threat of reduced payments from Medicare, which last year began withholding payments for certain preventable occurrences. Recently added to Medicare’s list of “never events” that aren’t reimbursed are DVT and pulmonary embolisms following knee or hip surgery. Hospital purchasing alliance Premier Inc. is working with about 250 hospitals on better compliance with DVT-prevention measures in a project co-sponsored by Medicare.

Last year, the Surgeon General’s office identified DVT prevention as a national priority. The Joint Commission, a nonprofit group that accredits hospitals, later this year will start asking hospitals to collect and report data on DVT, including what they are doing to prevent and treat the condition and how many cases of preventable DVT occur.

Weight as a Risk Factor

“People need to know that this is a risk, and there should be protocols in place to prevent it,” says Mr. Blau’s wife, Ana Blau, of Palm Beach, Fla. She says her husband was overweight, a risk factor for DVT, and compression stockings were used after his surgery.

But hospital records provided by the family show Mr. Blau wasn’t given medications used to prevent clots from forming, despite indications he might have been a candidate for these; Mr. Blau had a history of developing clots after past surgery, the records show. But he also had had spinal anesthesia, which increases the risk of bleeding, and may have been a factor in not providing a blood thinner.

Medical guidelines for preventing clots vary by the type of procedure being performed. Physicians also say the guidelines often have to be adjusted to fit the needs of individual patients. Brian Burnikel, medical director of the Total Joint Center at Greenville Hospital System in Greenville, S.C., says that in joint-replacement surgery, for instance, surgeons must balance the need to thin the blood to prevent a clot with the need to make sure patients don’t develop a hematoma — a collection of blood that can increase the risk of infection.

Risk of Bleeding

Patients who have had a spinal anesthetic are at increased risk of bleeding around the spine and paralysis from hematoma, so instead of using an aggressive anticlotting drug, patients may just get a milder thinner such as aspirin, Dr. Burnikel says. Surgeons operating on a leg might also reduce the risk of clots by avoiding putting the patient’s limb in an extreme position, he says. “You have to tailor what you are doing for each specific patient,” Dr. Burnikel says.

Medical experts say the incidence of DVT followed by pulmonary embolism, which is fatal about 30% of the time, is increasing in the hospital. That’s because many patients are older, more obese, and are undergoing more complicated and invasive surgeries. As many as two million Americans are estimated to suffer from DVT annually. Some have an inherited blood-clotting disorder that predisposes them to DVT. Medical conditions such as cancer, congestive heart failure, chronic respiratory failure, varicose veins, and estrogen treatment also are linked to increased risk.

The Coalition to Prevent Deep-Vein Thrombosis, funded by a maker of anticlotting drugs, Sanofi-Aventis, offers risk-assessment tools for consumers at PreventDVT.org. Nonprofit group ClotCare.com, which also receives some funding from pharmaceutical companies, offers information on DVT prevention, as well as research and therapies used to prevent blood clots.

After Going Home

Patient-advocacy groups say patients and families often aren’t advised of the risk of DVT while in the hospital. Patients also need to know about the risks of developing blood clots that could lead to pulmonary embolisms after they leave the hospital, and to be vigilant about reporting any symptoms to their doctors or seeking care in an emergency room. Among common symptoms are a sudden pain in the leg or shortness of breath.

After a minor outpatient procedure to scrape cartilage from her knee, 68-year-old Carol Barrett of Canada had complained to her family of pain in her legs and shortness of breath. But no one thought it was a sign of anything serious. Two days later, Ms. Barrett collapsed at her home in Newmarket, Ontario, and died. A blood clot that had apparently formed during the 10-minute surgery traveled from the deep veins in her leg to her lungs.

“We didn’t know about the possibility of blood clots after minor surgery,” says her daughter, Cathy Kincaide. “We now know there were some red flags, and had we been more informed, we might have acted on them and sought medical attention before the clot went to her lungs.” Adds Ms. Kincaide: “We need to educate patients that no surgery is minor, and you have to be aware of the risks pre- and post-surgery.”

Alpesh Amin, a specialist in hospital medicine at the University of California at Irvine, says that more than 60% of patients who enter the hospital have at least three risk factors for DVT, and the sedentary nature of most hospital stays just worsens the likelihood of a blood clot. Dr. Amin analyzed 72,337 cancer patients from a large hospital discharge database maintained by Premier, the hospital alliance. He found that only 27% of patients who were at risk for DVT between 2003 and 2005 were given appropriate prevention treatments recommended by the American College of Chest Physicians, whose DVT guidelines are the most widely used.

Dr. Amin says his hospital has adopted a computerized order system that prompts doctors to assess patients for DVT risk. Over the past few years, this has resulted in appropriate prevention measures being used 90% of the time, up from 30% prior to the program’s being adopted. “Every time you get on an airplane, the flight attendants go through a safety check, and that’s the kind of consistency we should have in trying to meet prevention guidelines,” Dr. Amin says.

Peering Into Veins

After completing a risk-assessment questionnaire when patients are admitted, doctors at some hospitals may order tests such as an ultrasound to take a closer look at a patient’s veins. But Richard Karulf, chief of surgery at Fairview Southdale Hospital in Edina, Minn., says screening may not always predict who will develop problems. “Some may have inherited problems we don’t know about,” Dr. Karulf says. Still, Fairview has reduced the incidence of pulmonary embolism following DVT since it began requiring doctors to evaluate patients for risk.

In 2004, North Mississippi Medical Center in Tupelo, Miss., had about 7.6 cases of DVT per 1,000 patients. It began using a protocol, or list of risk factors, that prompts each physician to assess incoming patients for risk. When appropriate, doctors then are prompted to order anticoagulant therapy and other preventive measures.

A year later, the hospital had one case of DVT per 1,000 patients, and in the past year, there hasn’t been a single case of pulmonary embolism in a surgical patient, says Michael O’Dell, the hospital’s chief quality officer.

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