This was April’s Journal Club article at the hospital and we did have a lively discussion with this one, as we’ve had a slew of patients diagnosed with DVTs at the hospital recently. Before that even happened, I picked this article to discuss, because it is a CPG. And that’s exactly what CPGs are for: to be discussed and disseminated.
In CPGs, no one picks one up unless they think the topic is important, so I won’t go into that part. Also, no one really cares how they went about finding the results, so I’ll skip that too. (If you really do want to see that, just read the article. That covers the first 2-3 pages.) I’m skipping stuff this time to save time, because this is a long one.
I will mention that this guideline is aimed at PTs, but “other health care professionals should find this CPG helpful” and that this CPG only covers lower extremity emboli in the adult– nothing on PE, upper extremity DVT or on the pediatric population.
In searching the literature, the researchers concluded 14 key action statements, which are as follows:
- “Physical therapists and other health care practioners should advocate for a culture of mobility and physical activity.” Prolonged bed rest is old school and doesn’t help anyone’s anything. If the patient is medically stable enough to be out of bed, they should be. End of story.
- “Physical therapists should screen for risk of VTE [venous thromboembolism] during initial patient interview and physical examination.” Risk factors for VTE include: history of embolism, age, active cancer/cancer treatment, severe infection, oral contraceptives, hormonal replacement therapy, pregnancy or given birth in last 6 weeks, immobility (bed rest, travel, fractures), surgery, anesthesia, critical care admission, central venous catheters, inherited thrombophilia and obesity. So ask about those things in your history and system screen. They also recommended selecting a screening tool from the following to use: Padua score for assessing VTE risk in hospitalized patients, the IMRPOVE VTE RAM, the Autar DVT Risk Assessment Scale and the Geneva Risk Score.
- “Physical Therapists should provide preventative measures for LE DVT [lower extremity deep vein thrombosis] for patients who are identified as being as risk for LE DVT. These measures should include education regarding signs and symptoms of LE DVT, activity, hydration, mechanical compression and referral for medical assessment.” Education is really stressed in this section. We should be covering: risk factors, consequences of DVT, possible interventions, signs/symptoms, importance of seeking medical help if DVT is suspected, importance of follow-ups and treatment adherence. And of course encouraging mobility. “Immobility” is defined as having one of the following: lower limb cast, bedridden, bedridden except for bathroom privileges, recent decreased ability to walk 10 feet for 72+ hours, being on a plane for >2-3 hours.
- “Physical therapists should recommend mechanical compression (eg, intermittent pneumatic compression [IPC], graded compression stockings [GCS]) when individuals are at moderate to high risk for LE DVT or when anticoagulation is contraindicated. ” Just do it, except keep an extra watchful eye on patients who have severe peripheral neuropathy, decompensated heart failure, arterial insuffiency, skin disease/ lesions.
- “Physical therapists should establish the likelihood of LE DVT when the patient has pain, tenderness, swelling, warmth or discoloration in the lower extremity.” Do so using the Wells criteria for LE DVT.
- “Physical therapists should recommend further medical testing after the completion of the Wells criteria for LE DVT prior to mobilization.” If they’ve got >2 points on the Wells stop what you’re doing and get them checked out medically.
- “When a patient has a recently diagnosed LE DVT, the physical therapist should verify whether the patient is taking an anticoagulant medication, what type […], and when […it…] was initiated.” Click here for a nice list of those meds (page 1), along with how long it takes for those meds to reach therapeutic levels. Print that one and tuck it away for safe keeping.
- “When a patient had a recently diagnosed LE DVT, physical therapists should initiate mobilization when therapeutic threshold level of anti-coagulants have been reach.” Knowing the above will tell you when it is ok to continue encouraging mobilization and continue therapy treatment.
- “Physical therapists should recommend mechanical compression (eg IPC, GCS) when a patient has an LE DVT.” Compression for everyone!
- “Physical therapists should mobilize patients after IVC filter placement once they are hemodynamically stable and there is no bleeding at the puncture site.” Mobilization for everyone ASAP!
- “When a patient with a documented LE DVT below the knee is not treated with anticoagulation and does not have IVC filter and is prescribed out of bed mobility by the physician, the physical therapist should consult with the medical team regarding mobilizing versus keeping the patient on bed rest.” Cover your butt.
- “Physical therapist should screen for fall risk whenever a patient is taking an anticoagulant medication.” They recommended using the CDC’s STEADI tool to screen and educate. Falls on anticoagulants are always ugly.
- “Physical therapists should recommend mechanical compression (eg, IPC, GCS) when a patient has signs and symptoms suggestive of PTS [postthrombotic syndrome].” PTS is what happens when the vessels get damaged with the DVT. Signs/symptoms include: chronic leg pain, leg feeling heavy, cramping, itching, venous ulceration, skin coloration changes.
- “Physical therapist should monitor patients who may develop long-term consequences of VTE (eg, LE DVT recurrence, PTS severity) and provide management strategies in order to improve quality of life.” Recurrence occurs in 5-10% within a year and 10-30% within 5 years. They suggested using the Pulmonary Embolism Severity Index and your eyeballs as the discoloration is highly correlated with Doppler results. And again, make sure these folk are educated and use mechanical compression as above.
So in conclusion, this CPG is awesome and has already helped guide my clinical decision making. READ IT!