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1st Qatar Conference on Safe Anticoagulation Management: New Advances & Trends
Hospital Acquired VTE: Input of Nurse February 27, 2015
Lynn B. Oertel, MS, NP-BC, CACPNursing Practice Specialist
Anticoagulation Management ServiceMassachusetts General Hospital, Boston, MA, USA
Seek nurse input to influence:
• Awareness• Education of workforce
• Establish a plan and collaborate with a multidisciplinary team
• Re-evaluate process – where are the gaps?
Individual level
Process and System level
The Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism
• 50% of cases of DVT are ‘silent’
• Often, first symptom is a fatal PE
• “DVT and PE represent a major public health problem”
• “DVT/PE….have negative impact on the lives of hundreds of thousands of Americans each year.”
http://www.surgeongeneral.gov/topics/deepvein/
Know Risk FactorsCaprini (surgical patients)
Age 41-60 yMinor SurgeryBMI > 25Swollen legsVaricose veinsPregnancy or postpartumHx unexplained/recurrent abortion
Oral contraceptive or hormone replacementSepsis (<1 mo)Serious lung diseaseAbnormal pulmonary functionCongestive heart failure (<1 mo)Hx of inflammatory bowel diseaseMedical patient at bed rest
1
Age 61-74 yArthroscopic surgeryMajor open surgery (>45 min)Laparoscopic surgery (>45 in)
MalignancyConfined to bed (>72 h)Immobilizing plaster castCentral venous access
2
Age ≥ 75 yHx of VTEFamily Hx of VTEFactor V LeidenProthrombin 20210ALupus anticoagulant
Anticardiolipin antibodiesElevated serum homocysteineHeparin-induced thrombocytopeniaOther congenital or acquired thrombophilia
3
Stroke (< 1 mo)Elective arthroplasty
Hip, pelvis or leg fractureAcute spinal cord injury (< 1 mo) 5
Padua Prediction Score (medical patients)
Active cancer 3
Previous VTE 3
Reduced mobility 3
Known thrombophilic condition 3
Recent (<1 mo.) trauma +/or surgery 2
Age ≥ 70 y 1
Heart and/or respiratory failure 1
Acute myocardial infarction or ischemic stroke
1
Acute infection and/or rheumatologic disorder
1
Obesity (BMI ≥ 30) 1
Ongoing hormonal treatment 1
High risk ≥ 4 points High risk ≥ 5 points, moderate 3-4, low 2, very low 0-1
ACCP Consensus Conference on Antithrombotic Therapy (9th Ed)
• Evidence-based clinical practice guidelines and
Chest 2012. 141(2 suppl)www.chestjournal.org
VTE Prevention in……• Acutely ill hospitalized medical
patients (Kahn SR et al. Chest 2012. 141:(2_suppl):e195s-226s)
• Non-orthopedic surgical patients (Gould MK et al. Chest 2012. 141 (2_suppl):e227s-277s)
• Orthopedic surgical patients (Falck-Ytter et al. Chest. 141 (2_suppl): e278s-325s)
• Stroke patients (Lansberg et al. Chest. 141 (2_suppl): e601s-636s)
Access via: www.excellence.acforum.org Resource Center Disease State Management VTE Prevention and Treatment
From: University of WashingtonAccess on: www.excellence.acforum.org Resource Center Comprehensive Toolkits
This pocket guide can be accessed on www.excellence.acforum.org Resource Center
From: University of WashingtonAccess on: www.excellence.acforum.org Resource Center Comprehensive Toolkits
Risk stratification of medical patients
From: MGH VTE Prophylaxis policy. Based on UCSD, UCSF and Emory Healthcare VTE protocols. Accessed at Society for Hospital Medicine: http://www.hospitalmedicine.org/Web/Clinical_Topics/vte.aspx
http://www.outcomes-umassmed.org/IMPROVE/
The IMPROVE Registry (International Medical Prophylaxis Registry on Venous Thromboembolism)
• Prospective cohort of hospitalized medical patients
• 11 countries• Risk calculators for web or
iphone
How best to make a difference with VTE prophylaxis?
TEAM APPROACH
Multidisciplinary TEAM
• Physicians • Pharmacists • Nurses – at the bedside, leaders at the front line• Case Managers – discharge planning• Information Technology / Informatics• Administrative Liaison• Data Manager / Analyst• Quality and Safety Staff• Regulatory Compliance
IT = information technology
www.ahrq.gov/.../quality-patient-safety/patient-safety-resources/resources/vtguide/vtguide.pdf http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/vtguide/index.html
• Focuses on the basics of quality improvement
• Physician driven quality improvement effort
• Explains how to:– take essential first steps– lay out the evidence and
identify best practices– analyze care delivery– track performance with
metrics– layer intervention– continue to improve
Approaches:1) Opt out approach2) No VTE risk assessment model3) Buckets of Risk4) Individualize point-based risk assessment model
Maynard G et al. J Hosp Med. 2013; 8:582-585
Multidisciplinary TEAM
• Backbone of quality improvement (QI) efforts• Impact the interventions developed AND their
implementation• Synergistic
– Increases productivity: The TEAM is more than the sum of all individual team members
Characteristics of an ideal VTE protocol
1) Standardized (and easy to use) VTE risk assessment2) Menu of evidence-based options for prophylaxis3) List of contraindications to pharmacologic options is
presented
‘85/15 rule’ – make it fit for MOST patients
Determine who performs the VTE risk assessment
• Is responsible for determining risk level AND ordering appropriate prophylaxis (physicians, nurse practitioners, physician assistants)
• BACK up (team effort) by nurses and pharmacists– Identify who is NOT on prophylaxis – why not?– Promote adherence – it is essential for success to
both pharmacologic and mechanical prophylaxis methods
How often is a VTE Risk Assessment needed?
• Known key intervals: admission, ICU transfer, post surgery
• Change in patient condition (new risk factors now present)
• BACK up (team effort) by nurses and pharmacists
What gets in the way of effective VTE prophylaxis?
• Uninformed of the need• Underestimate true clot risk• Overestimate bleeding risk• Lack of easy, standardized, validated tools• Lack of adherence to mechanical prophylaxis
– Graduated compression stockings (knee vs. thigh length)– Intermittent pneumatic compression (IPC) devices
• Difficult to sustain awareness
How to succeed
• Institutional support form the top• Multidisciplinary team
– Physician champion• Educate and gain consensus among ALL disciplines• Develop protocols and identify key ‘transitions’
– Admission, transfer to intensive care, surgery, others• Computerized physician order entry system or standardized order
sets for VTE prevention:– Electronic alerts (Kucher et al. NEJM. 2005; 352:969-977– Human alerts (Piazza et al. Circulation. 2009:2196-2201)
• Pilot test, evaluate (get some data), re-adjust, try again• Validate with objective feedback in real time to TEAM
Plan/Do/Study/Act (PDSA) cycle
How nurses can make a difference
• Determine who has VTE prophylaxis (or not)
• Categorize patients visually by:– Pharmacologic prophylaxis
(green zone)– Mechanical prophylaxis only
(yellow zone)– NO proplylaxis (red zone)
Goal MOVE OUT of the RED!
Make is simple. Make it easy.
• Make the desired action: – the default action (i.e., not doing the desired action
requires active opting out)– is prompted by a reminder or a decision aide– is standardized into a process– is scheduled to occur at known intervals– has built in redundancies (other team members!)
• Support the TEAM effort
Maynard G, Stein J. Designing and Implementing Effective VTE Prevention Protocols: Lessons from Collaboratives. J Thromb Thrombolysis 2010 Feb:29(2):159-166
Don’t forget the patient educational needs at discharge
• Should prophylaxis extend beyond acute hospitalization?
• If high risk, can patient:– recognize potential signs and symptoms of VTE? – take the right action and seek medical evaluation without
delay?
• Does patient understand discharge medications provided to him?
Questions?