What is the recommended DVT (Deep Vein Thrombosis) prophylaxis for patients in a transitional care unit setting awaiting long-term care?

DVT Prophylaxis in Transitional Care Units Awaiting Long-Term Care

Patients in transitional care units awaiting long-term care placement should generally NOT receive routine pharmacological DVT prophylaxis unless their clinical status changes to acute illness. 1

Key Recommendation for Chronically Ill Patients

The American Society of Hematology (ASH) 2018 guidelines specifically address this population and suggest not using VTE prophylaxis in chronically ill medical patients, including nursing home patients, compared with using any VTE prophylaxis (conditional recommendation, very low certainty in evidence). 1

Critical Distinction: Acute vs. Chronic Status

The guidelines make an important caveat: if a patient's status changes to acute, other recommendations would apply. 1 This means you must reassess daily for:

• New acute medical illness (infection, heart failure exacerbation, respiratory failure) 1
• Sudden immobilization beyond baseline functional status 1
• Active cancer diagnosis or treatment 1
• Recent trauma or surgery (<1 month) 1

When to Initiate Prophylaxis in This Setting

Start pharmacological prophylaxis if the patient develops:

• Acute medical illness requiring intensive medical management (use LMWH, UFH, or fondaparinux) 1, 2
• Critical illness requiring ICU-level care (use LMWH or UFH) 1, 2
• High VTE risk score (Padua score ≥4 or IMPROVE VTE score ≥2) 1, 2

Rationale for This Approach

The evidence shows that chronically ill patients in long-term care facilities have a different risk-benefit profile than acutely ill hospitalized patients. 1 The baseline VTE risk in stable, chronically ill patients is substantially lower than in acute medical illness (0.3% in low-risk vs. 11% in high-risk acute patients). 1

The bleeding risk from routine prophylaxis may outweigh the VTE prevention benefit in this stable population. 1

Practical Implementation Algorithm

Daily assessment should include:

1. Is the patient acutely ill? (new infection, decompensated heart failure, respiratory distress) 1

   • If YES → Initiate pharmacological prophylaxis with LMWH (preferred) or UFH 1, 2
   • If NO → Continue without prophylaxis 1

2. Does the patient have acceptable bleeding risk? 2

   • If bleeding risk is HIGH → Use mechanical prophylaxis (intermittent pneumatic compression devices preferred over graduated compression stockings) 2, 3
   • If bleeding risk is ACCEPTABLE → Use pharmacological prophylaxis 2

3. What is the expected duration of stay? 1

   • Prophylaxis should continue only during the acute illness phase 1
   • Do NOT extend prophylaxis beyond hospital discharge or resolution of acute illness 1

Common Pitfalls to Avoid

• Do not automatically start prophylaxis simply because the patient is in a healthcare facility—this is not an acute hospitalization for medical illness 1
• Do not confuse baseline limited mobility with acute immobilization requiring prophylaxis 1
• Do not continue prophylaxis indefinitely if started during an acute episode—discontinue when acute illness resolves 1
• Do not ignore admission from long-term care as a risk factor if the patient subsequently develops acute illness requiring readmission (this is actually a risk factor for VTE despite prophylaxis) 4

Special Considerations

If the patient requires transfer back to acute care for any reason, reassess using standard acute medical patient criteria with risk stratification tools (Padua or IMPROVE scores). 1, 2

The presence of indwelling central venous catheters is a significant risk factor for VTE and may warrant prophylaxis even in otherwise stable patients. 4