Review of the Evidence Regarding Safe Activity and Mobilization with Acute Venous Thromboembolism

By: Michelle de la Garza OTD, OTR/L

Photo credit: Pulmonary Pathology / Foter / CC BY-SA

Photo credit: Pulmonary Pathology / Foter / CC BY-SA

Every year in the United States it is estimated that up to 2 out of every 1000 people are diagnosed with a deep vein thrombosis (DVT) or pulmonary embolism (PE). Between 10 to 30 percent of those will be cases that end in death within 30 days of diagnosis. Additionally, sudden death occurs in nearly 25 percent of all diagnosed PEs (Centers for Disease Control and Prevention, 2014). The risk factors for developing a DVT or PE include high blood pressure, history of stroke, chronic heart disease, and chronic obesity (National Institutes of Health, 2011). With these comorbidities on the rise (National Institutes of Health, 2011), it is likely that the number of patients with DVT and PE will also rise. As health care systems are pressured to provide care with shorter lengths of stay and better clinical outcomes, it is important for occupational therapists to utilize best practice in treating this patient population.

Clinical Scenario

A physician writes an order for OT Eval and Treat on a patient newly diagnosed with a PE. Because the health care center is striving to keep length of stays short and social work is pressing you for discharge recommendations, you want to initiate OT services as soon as possible to assess the patient’s independence and safety with ADLs. However, you don’t want to do so if the patient is medically unstable, putting the patient at greater risk for cardiac arrest and other complications. You need a quick tool to verify that the patient is reasonably stable and appropriate to begin OT treatment.

Pulmonary Embolism Severity Index

 

The Pulmonary Embolism Severity Index (PESI) was created to categorize the severity and risk of mortality for patients with PEs. The developers of this tool identified 11 independent indicators that have been clinically associated with mortality in patients diagnosed with acute PE (Aujesky et al., 2005). Patients who are hemodynamically stable will score in the Low Risk of mortality range – Classes I and II – with scores of less than or equal to 65 and 66-85, respectively. Hemodynamically unstable patents are in a High Risk of mortality range – Class V – with a score greater than 125. Patients with scores of 86-105 and 106-125 – Classes III and IV, respectively – are considered Intermediate-High Risk of mortality (Aujesky et al., 2005).

Information regarding parameters for recommended activity or recommended bed rest for a PESI score above 125 was unable to be found in Level I or II evidence pools. Clinical judgment and/or physician specific protocols are likely used in such cases. When considering the criteria for scoring the PESI, the possibility that a patient with a high score would also have comorbidities that further complicate activity is quite likely.  So regardless of pulmonary status, the treating clinician is surely assessing other medical issues before proceeding with treatment. Overall, studies using the PESI scores have indicated that patients with non-High Risk scores (<125) have safely been treated without bedrest or activity restriction and discharged within 24 hours of diagnosis. These patients do not show a statistically significant increase in mortality or complications as compared to those patients treated with longer inpatient stays, including days of restricted activity (Yoo, Queluz, & El Dib, 2014; Othieno, Abu Affan, & Okpo, 2007). This body of research uses subcutaneous Heparin (1mg BID) to treat the PE, which is considered best practice due to its effectiveness, fast results, and easy administration (Yoo et al., 2014; Othieno et al., 2007; Aujuesky et al., 2014). These findings indicate that patients with acute PEs and appropriate anticoagulation treatment who also have non-High Risk PESI scores can be considered for safe early mobilization and to resume ADL performance. This supports related research regarding DVT best practices including: increased physical activity reduces recurrence of DVT, reduces extension of DVT, and can reduce pain symptoms of DVT in conjunction with anticoagulation treatment (Kahn, Shrier, & Kearon, 2008; Blattler & Partsch, 2003).

An alternate treatment for PE is use of a thrombolytic agent. This is contraindicated in PESI class I and II patients due to an increased incidence of major bleeding events and intracranial hemorrhage. Anticoagulation therapy is preferred for low and intermediate-high risk PEs (Riera-Mestre, Becattini, Giustozzi, & Agnelli, 2014).

Special Considerations

As with any protocol or assessment tool, clinical reasoning and clinical observations must be considered before and during occupational therapy treatment. Additional considerations include comorbidities such as cancer and history of cancer, pregnancy, trauma, and renal insufficiency (Aujesky et al., 2005; Yoo et al., 2014; Othierno et al., 2007). Patients with these comorbidities were widely excluded in the research. Additionally, therapists should identify the method of anticoagulation being used with each patient, as standardization of the PESI tool used only patients treated with subcutaneous Heparin (Aujesky et al., 2005).

Conclusion

The PESI tool can be useful in the clinical decision making process when working with patients diagnosed with acute PE. When coupled with good clinical reasoning and collaboration with the interprofessional care team and the ordering physician, the PESI score may be used to safely increase early mobilization, facilitate the return to ADL performance, shorten length of stay, and decrease patient mortality.

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About the Author

Michelle de la Garza OTD, OTR/L lives in Omaha, Nebraska and is a graduate from Creighton University.  She currently practices in an acute care hospital, as well as is involved with lab instruction for the Creighton University entry level OTD program.

References

Aujesky, D., Obrosky, D.S., Stone, R.A., Auble, T.E., Perier, A., Cornuz, J., … Fine, M.J. (2005). Derivation and Validation of a Prognostic Model for Pulmonary Embolism.

American Journal of Respiratory and Critical Care Medicine, 172, 1041-1046. DOI: 10.1164/rccm.200506-862OC.

Blattler, W & Partsch, H. (2003). Leg Compressions and Ambulation is Better Than Bedrest for the Treatment of Acute Deep Venous Thrombosis. International Angiology, 22(4), 393-400.

Centers for Disease Control and Prevention. (2014, December 10). Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)- Blood Clots Forming in a Vein: Data & Statistics. Retrieved from http://www.cdc.gov/ncbddd/dvt/data.html

Fraga, M., Taffe, P., Mean, M., Hugli, O., Witzig, S., Waeber, G., & Aujesky, D. (2010). The Inter-Rater Reliability of the Pulmonary Embolism Severity Index. Thrombosis and Haemostasis, 104, 1258-1262. DOI:10.1160/TH10-07-0426

Kahn, S.R., Shrier, I., & Kearon, C. (2008). Physical Activity in Patients with Deep Vein Thrombosis: A Systematic Review. Thrombosis Research, 122, 763-773. DOI:10.1016/j.thromres.2007.10.011

National Institutes of Health. (2011, July 1). Who Is at Risk for Pulmonary Embolism? Retrieved from http://www.nhlbi.nih.gov/health/health-topics/topics/pe/atrisk

Othieno, R., Abu Affan, M., & Okpo, E. (2007). Home Versus In-patient Treatment for Deep Vein Thrombosis. Cochrane Database of Systemic Reviews, 3, 1-28. DOI: 10.1002/14651858.CD003076.pub2

Riera-Mestre, A., Becattini, C., Giustozzi, M,. & Agnelli, G. (2014). Thrombolysis in Hemodynamically Stable Patients with Acute Pulmonary Embolism: A Meta-Analysis. Thrombosis Research, 134, 1265-1271. DOI: 10.1016/j.thromres.2014.10.004

Yoo, H.H.B., Queluz, T.H.A.T, & El Dib, R. (2014). Outpatient Versus Inpatient Treatment for Acute Pulmonary Embolism. Cochrane Database of Systematic Reviews, 11, 1-33. DOI:10.1002/14651858.CD010019.pub2

 

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