Despite increasingly detailed efforts to optimize prophylaxis, venous thromboembolism (VTE) remains a leading cause of morbidity and mortality after traumatic injury. Over the last two decades, landmark studies have improved the efficacy of prophylaxis by identifying the utility of anti-Xa guidance for enoxaparin dose adjustment1 and individualized enoxaparin dosing2; sped the initiation of safe prophylaxis in patients with traumatic brain injury3 or blunt solid organ injury4; demonstrated the increased VTE risk that occurs when medication doses are missed5; and enlisted patients and nurses in multidisciplinary educational efforts to improve medication adherence.6 Despite these efforts, morbidity and mortality from VTE remain unacceptably high, and additional improvements are needed.
Van Gent et al7 use ‘door-to-prophylaxis’ time as a novel quality improvement metric in prevention of VTE following trauma. In their manuscript, they have identified and described a new tool to use toward our lofty goal of complete VTE prevention. They evaluated a high-risk subset of adult major trauma patients who required emergency-release blood products either prehospital or in the emergency department, and analyzed the time from hospital arrival to the first dose of prophylaxis as a unique risk factor for VTE development, alongside more classic contributors. After reviewing more than >2000 patients, they confirmed that any delay in prophylaxis administration increases the incidence of VTE, even when controlled for traditional risk factors; on average each hour delay increased the likelihood of VTE by 1.5%.
While many of the classic VTE risk factors, such as injury patterns, age, comorbidities, and ventilator requirements, are difficult or impossible to modify, ‘door-to-prophylaxis’ is an accessible, measurable, and effective target for improving VTE outcomes. This manuscript is a call-to-action for all trauma centers to establish protocols ensuring initiation of enoxaparin at the time of admission in appropriate patients. Future studies are needed to establish benchmarks for optimal door-to-prophylaxis times for various injury patterns, which will allow for the creation of best practices to further limit VTE risk in severely injured trauma patients.
