Variation exists in venous thromboembolism prophylaxis in traumatic brain injury despite national guidelines: insights from a recent AAST survey study

Keith Walter Burczak; Jan-Michael Van Gent; Devi Bavishi; Gabrielle E Hatton; Patrick B Murphy; Asanthi Ratnasekera; Thomas W Clements; Rachel S Morris; Christopher Tignanelli; Bryan A Cotton; Thaddeus J Puzio

doi:10.1136/tsaco-2024-001708

Variation exists in venous thromboembolism prophylaxis in traumatic brain injury despite national guidelines: insights from a recent AAST survey study

Trauma Surg Acute Care Open. 2025 Oct 23;10(4):e001708. doi: 10.1136/tsaco-2024-001708. eCollection 2025.

Affiliations

¹ The University of Texas Health Science Center at Houston, Houston, Texas, USA.
² Division of Trauma and Surgical Critical Care, The University of Texas Health Science Center at Houston, Houston, Texas, USA.
³ General Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA.
⁴ Surgery, University of Texas McGovern Medical School, Houston, Texas, USA.
⁵ Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
⁶ Surgery, Christiana Care Health Services Inc, Newark, Delaware, USA.
⁷ Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA.
⁸ Department of Surgery, University of Minnesota System, Minneapolis, Minnesota, USA.
⁹ Surgery, University of Texas John P and Katherine G McGovern Medical School, Houston, Texas, USA.
¹⁰ General Surgery, University of Texas McGovern Medical School, Houston, Texas, USA.

Abstract

Background: Best practice guidelines from trauma-focused organizations support early (<72 hours) venous thromboembolism (VTE) chemoprophylaxis initiation in traumatic brain injury (TBI) patients. Recent literature suggests that an even more aggressive initiation (24 hours) is safe and efficacious. It is unknown how current practice aligns with the existing literature and best practice guidelines. We performed a national survey to characterize variation in trauma surgeons' reported practices and attitudes regarding VTE chemoprophylaxis initiation in TBI patients with the hypothesis that they will vary widely.

Methods: All 1700 American Association for the Surgery of Trauma members were surveyed online. Members who routinely cared for patients with TBI were asked to proceed with the survey. Descriptive data were reported. The questions characterized institutional guidelines, and if none existed, individual practice patterns regarding goal timeline of VTE chemoprophylaxis in TBI patients.

Results: 374 members (22%) completed the survey. Most respondents worked at academic institutions (40%) and represented a level one trauma center (44%). Enoxaparin was the most common VTE chemoprophylactic (73%) with most using weight-based dosing (76%) and anti-Xa testing (75%). Institutional policies that included a protocol for VTE chemoprophylaxis initiation in TBI patients were used by 86% of respondents. In those with established protocols, 59% reported being mostly compliant. Reasons for delay of VTE chemoprophylaxis included worry about progression of TBI and disagreement with consulting services. 293 (80%) of respondents reported protocolized repeat head CT within 4-12 hours after initial CT (60%). In response to a clinical scenario, 43% of respondents reported that their goal timeline for initiating VTE prophylaxis was within 24 hours of a stable head CT.

Conclusions: Despite national guidelines, substantial variation remains in the timing of VTE chemoprophylaxis in TBI patients. Passive strategies, such as institutional guidelines alone, are insufficient. Institutions must adopt more effective implementation tactics-including protocol-enforced order sets, automated clinical decision support, and shared governance models with ancillary services-to ensure timely, evidence-based care.

Level of evidence: Level V.

Keywords: Practice Patterns, Physicians'; Thromboembolism; Time-To-Treatment; traumatic brain injury.