joysmithportfolio.weebly.com · Web viewThe root causes for VTEs were identified and acted on with education for clinicians and patients. ... (DVT) is a significant health issue,

PREVENTING VENOUS THROMBOEMBOLISM 1

Preventing Venous Thromboembolism in the Inpatient Population

Joy Smith, RN, CHSP, CHSN

School of Nursing

Ferris State University

Author Affiliations: Float Pool Team Leader, Good Samaritan Medical Center (GSMC).

Correspondence: Joy Smith, GSMC, 200 Exempla Circle, Lafayette, CO. 80026.

Email: [email protected].

Declarations: No conflicts of interest, and no financial compensation was received.

Article Word Count: 3997

mailto:[email protected]


Abstract

Venous thromboembolism (VTE), which includes pulmonary embolism (PE) and deep vein

thrombosis (DVT) are preventable complications. The focus of this quality improvement (QI)

project was reduction of VTEs in the inpatient population at Good Samaritan Medical Center in

Lafayette, Colorado. Good Samaritan Medical Center data from 2018-2019 determined that

hospital VTE rates were higher than many other hospitals. In response to this data, VTEs were

identified by the performance excellence group as an opportunity for improvement. A task force

was formed with a goal rate of zero DVTs per month. The root causes for VTEs were identified

and acted on with education for clinicians and patients. Additional audits were completed for

sequential compression device (SCD) compliance, heparin administration, physician VTE order

sets, and evidence based practice (EBP) reviews for improvement opportunities. At the

conclusion of the project, the incidence of VTEs, audits, data collection, and nursing charts were

analyzed to assess outcomes. It was determined that zero VTEs were reported for 221 days.

There was an increase in VTE education, correct data charting by nurses, and an increase in

patient use of SCDs, ambulating frequency, and acceptance of anticoagulation medication

administration. Changes were made to hospital policies, the physician order entry VTE order

sets, and the patient medical administration record to eliminate confusion and discrepancies

when nurses administer anticoagulation medications. Data collected from the QI project

determined additional changes needed for continuous QI.

Keywords: venous thromboembolism, deep vein thromboembolism, pulmonary embolism,

sequential compression devices, anticoagulation medications


Preventing Venous Thromboembolism in the Inpatient Population

Pulmonary embolism (PE) and deep vein thrombosis (DVT) is a significant health issue,

causing one person in the United States (U.S.) to die every six minutes (Centers for Disease

Control, 2020a). Venous thromboembolism (VTE) is a term for both PEs and DVTs. VTEs

affect the elderly, hospitalized, injured, sick, immobile, pregnant, or patients within 30 days of

hospital discharge. Venous thromboembolisms can be decreased with prophylaxis by 30-65%

(Agency for Healthcare Research and Quality [AHRQ], 2020), however, only 60% of surgical

patients and 40% of medical patients with risk factors receive appropriate VTE prophylaxis

(Cohen et al., 2008). Venous thromboembolisms can be detrimental and cause decreased

mobility, extended length of stay, additional expense to patients and hospitals, increased

readmissions and fatality rates, and risk for bleeding for patients on anticoagulation medications.

Patients also experience anxiety, stress, and fear of additional blood clots. The aim of this quality

improvement (QI) project practicum was to mitigate VTEs.

Literature Review

Venous thromboembolism is a significant health threat, affecting up to 900,000 people

annually, with a death rate up to 100,000 (AHRQ, 2020). Within one month of VTE diagnosis,

10%-30% will die, and the first symptom for 25% of individuals with a PE is death (AHRQ,

2020). For people who experienced a previous DVT, 30%-50% will have complications long-

term, and within 10 years, 33% will experience another DVT (AHRQ, 2020). Anticoagulation,

which is preferred treatment for thromboembolisms, provides effective results in most patients.

The 2008 U.S. Surgeon General’s Call to Action to Prevent VTEs, Section IV provides

guidelines to reduce VTEs using communication, education, action, research, and evaluation

(United States Office of the Surgeon General, 2008). The Center for Disease Control and


Prevention (2020b, [CDC]) promotes three strategies to prevent healthcare-associated VTEs:

better monitoring, promoting and identifying best practices, and increasing awareness and

education (Smith, 2020).

The Joint Commission (2019) national inpatient quality core measures for preventing

VTEs are: VTE prophylaxis, Intensive Care Unit (ICU) VTE prophylaxis, VTE patients with

anticoagulation overlap therapy, VTE patients receiving unfractionated heparin with monitoring,

VTE discharge instructions, and preventable VTE. This QI project focus is VTE-6, hospital

associated potentially-preventable VTE (Smith, 2020). According to a systematic review

containing five random control trials (RCTs) and 1,072 trauma patients, DVTs were significantly

decreased using SCDs and foot pumps (Ibrahim et al., 2015). A Cochrane study containing 9,137

participants and 22 trials, determined that combining SCDs with pharmacological prophylaxis

decreased the occurrence of DVTs more than just one or the other (Kakkos et al., 2016).

Unfortunately, 50% of VTEs are healthcare-associated, and less than 50% of inpatients are not

receiving the VTE prophylaxis that is available (AHRQ, 2016). According to Smith (2020), in a

2017 quasi-experimental study on an outpatient orthopedic surgery unit, 30 nurses were tested on

DVT prevention knowledge. Then they were trained according to the Nursing Care Standards for

DVT prevention. At the conclusion of the study, the results suggested incidence of DVTs was

significantly reduced after training (El-SayedEad et al., 2017).

According to two different hospitals, implementing effective VTE order sets can reduce

VTEs. A John Hopkins team used an algorithm for 16 different patient groups to create “smart”

order sets, which increased use of VTE prophylaxis (Streiff et al., 2016). A medical center in

Phoenix used VTE order sets to determine patient risk level at admission and transfer, then


selected appropriate VTE prophylaxis. The hospital used audits to monitor and improve usage,

and achieved a 59% reduction in VTEs (Beresford, 2012).

With COVID-19 onset, there is ongoing research on how COVID-19 affects

coagulopathy. A single-center cohort study with 198 hospitalized COVID patients, found that

VTE risk in COVID-19 patients was very high, with 16% acquiring at seven days, 33%

acquiring at 14 days, and 41% acquiring at 21 days (Middeldorp et al., 2020).The study results

showed patients placed on anticoagulation at admission, did not acquire VTEs. The study

stressed importance of early diagnostic imaging in Intensive Care Unit (ICU) patients, and

possible higher intensity thrombosis prophylaxis decreases VTEs and mortality (Middeldorp et

al., 2020).

Nurses play a major role in helping prevent VTEs by encouraging early and frequent

ambulation, teaching passive leg exercises and promoting SCDs. Nurses monitor lab results, and

assess patients for bleeding complications from anticoagulants (D’Alesandro, 2016).

Patient education is highly recommended to reduce VTEs. The CDC developed a

campaign called Stop the Clot, Spread the Word. The CDC created colorful charts, education,

and checklists for helping community members and hospitalized patients to take control of their

health by preventing blood clot risk factors (CDC, 2020a). Preventing VTEs requires the

healthcare team and patient be provided education, and follow prevention guidelines.

Change Theory and Leadership Theory

The nursing theory that aligns with this project is the goal attainment theory, by Imogene

M. King (King, 1989). The theory of goal attainment is based on the belief that a good

relationship between the nurse and patient increases opportunities for patient involvement in

their plan of care (King, 1989). Effective communication allows the nurse and patient to set


mutual goals, ways to pursue goals, and a method to determine goal obtainment. If education is

provided on VTE severity, heparin necessity, hydrating, wearing SCDs, ambulation, and self

Lovenox injection teaching, the patient will participate in VTE prevention (Smith, 2020).

A transformational leadership style with high reliability was used for this project.

Transformational leadership is based upon relationship building through a shared vision and

mission (Frandsen, 2015). Ciprano (2008) discusses how high reliability helps organizations

build safer systems by standardizing processes. High reliability promotes a “Just and Safe

Culture” that encourages staff to report “fall-outs” that are observed without repercussions

(Smith, 2020). The GSMC QI task force and the Professional Governance Council (PGC)

collaborated on unit quality scorecards to increase availability of data and promote transparency.

All staff were encouraged to participate in efforts to reduce VTEs (Smith, 2020).

Quality Improvement Project Plan

The QI project focus was to decrease and eliminate VTEs. The 2018 National Surgical

Quality Improvement Program (NSQIP), suggests GSMC patients were 16% more likely to

acquire a VTE 30 days post-operatively (post-op) than other NSQIP hospitals, and GSMC

patients with hip fractures were 43% more likely to acquire a VTE within 30 days post-op

(NSQIP, 2018). The Leapfrog hospital safety grade data reported that 5.13 out of 1,000 people

who had surgery in 2019 at GSMC acquired blood clots (The Leapfrog Group, 2020). GSMC

found a lack of consistency in ensuring validation and accountability of standardized bundle

measures for preventing VTEs. In response to this data, the ten patients who acquired VTEs at

GSMC in 2019 (GSMC PSI-12 Coding Data, 2019), and two patients in January 2020, VTEs

were identified by the performance excellence group as an improvement opportunity. A quality

task force was assembled, with the goal of zero DVTs per month. Root causes for VTEs were


identified, policies and computerized physician order entries were analyzed, education for

clinicians and patients was provided, SCD walk through compliance, SCD, and heparin

administration charting audits were completed, and evidence based practice (EBP) was reviewed

for improvement opportunities. At the project conclusion, the incidence of VTEs, audits, data

collection, and nursing charts were analyzed to assess outcomes. Data collected determined

additional measures for continuous QI.

The MSN was designated as the Subject Matter Expert (SME)/Clinical RN (CRN). The

SME/CRN was responsible for leading the work with nursing manager lead guidance. The

SME/CRN collaborated with physicians, co-leads, managers, directors, pharmacists, educators,

data analysts, and other leaders. Validated data from unit quality scorecards, committee

objectives, and initiative progress was conveyed in monthly VTE task force meetings. The

SME/CRN attended additional focused meetings and acted as a VTE prevention resource for

clinicians. The project analyzed previous VTEs and patient charts to see where measures were

not being met. Nurses were asked for suggestions to prevent VTEs, and improvement

opportunities were investigated. The SME/CRN reviewed evidence to determine best practices

and examined the hospital’s current VTE prevention practices, and if these practices were being

adhered to. Root causes were identified using a fishbone diagram, and a failure mode and effects

analysis (FMEA) was created (Smith, 2020). Nurses were provided education on VTEs, best

methods for prevention, and how to educate patients. At the project conclusion, the incidence of

VTEs, audits, and nursing charts were reanalyzed to assess outcomes (Smith, 2020). Graphs

(Appendix A) were created to show data before and after education was received. An evaluation

determined what methods were successful and what potential changes will need to be made. A

recognition plan was put in place for units that met or exceeded the quality standard as evidenced


by unit quality scorecards. The SME/CRN was awarded the GSMC Clinical Nurse Quality

Champion in September 2020 (See Appendix H).

The competencies of safety, teamwork and collaboration were used in this project. Using

safety competency, team members designed, promoted, and modeled effective technology use,

and standardized practices that supported safety and quality. Improving and creating processes

that promote SCD use, using tools and techniques, and better education for staff and patients

better supported the health and safety of patients during their hospital stay and after discharge

(Smith, 2020). Nurses encouraged patients to ambulate, use range-of-motion exercises and wear

SCDs. Nurses educated patients about blood clot risks using the CDC handouts. They also taught

the patients importance of heparin and Lovenox injections. According to the American Heart

Association (2020), dehydration leads to blood vessel narrowing, thickening patient’s blood, and

increasing VTE risk. Nurses helped ensure that patients were well hydrated to prevent hyper

coagulopathy, and to immediately report any sudden shortness of breath, or signs and symptoms

of VTE (Smith, 2020).

Clinical staff provided feedback of improvements they would like implemented and

provided information on near misses to help improve processes. Using interprofessional

collaboration, the project was improved. Improving processes and quality is an ongoing process.

Consistent and continual monitoring is also important to sustain the program’s effectiveness

long-term (Smith, 2020).

The project was based on four professional standards: assessment, identification,

planning and implementing. First, by using the assessment standard, available data was gathered

and synthesized, and discussed among the VTE task force. This information was analyzed to

identify patterns and variances to help improve and develop measures for decreasing VTEs in the


inpatient population. The second standard was identification of problems, issues, and trends.

During this phase, current practices and actual or potential barriers that may cause VTE risk to

the patients was determined (Smith, 2020). These problems, issues, and trends were reported, so

risks could be mitigated, to achieve a decrease in the number of VTEs. The planning phase was

the third standard that was met in this project. In the planning phase, the plan was documented

and clearly communicated with the preceptor, task force, and leadership that were involved with

the initiative. Clear communication between all involved parties helped clarify the plan, make

changes, and move ahead (Smith, 2020). The fourth standard that was met was quality of

practice. This was accomplished by conferring with leaders in VTE prevention and studying EBP

to identify best methods of reducing VTEs. Methods were used to help promote best practices,

by educating users and using strategies to encourage compliance (Smith, 2020).

Quality Improvement Project Task Force

The Practicum and Project task force began August 31, 2020 at GSMC. The project

contained goals and sub-goals with actions needed. Two goals were identified. The first goal was

to meet with the task force to determine VTE prevention strategies. Sub-objectives to meet this

goal were determining root causes, examining evidence-based practice, and physicians

contributing input on order sets and medications. The second goal was implementing strategies

to prevent VTEs. The sub-objectives were to provide education for nurses and patients, and to

physicians if there were order set changes. Other sub-objectives were to review current policies,

protocols and data, process changes, and to verify adequate VTE prevention equipment.

Activities to complete sub-objectives were identified and given to participants.

Tackling the root causes, and finding solutions is a critical component of VTE

prevention. The FMEA is an evaluation tool to identify failures that are known or unknown. The


FMEA is utilized to determine all the ways the process could fail, estimate consequence and

probability of each failure, and determine what needs to be done to prevent the failures from

occurring (Sherwood & Barnsteiner, 2017). An FMEA was used to determine the effects, cause,

controls and recommended actions to prevent failures in decreasing the VTE rates. The RCA

(see Appendix F) and FMEA (see Appendix G) were used by the SME/CRN. One failure mode

would be clinicians contributing to VTEs if a patient is not encouraged to ambulate, or VTE risks

are not thoroughly explained. Patients that are non-compliant also contribute to VTEs. Root

causes of why patients are refusing injections, medications, or SCDs were investigated. It was

determined that further education for patients and clinical staff was needed. Not using SCDs also

contributes to VTEs. The SME/CRN presented ideas for nursing and patient education that were

accepted by the task force. The SME/CRN stressed the importance of patients understanding

blood clot risks, and that patients would participate in their plan of care, and be more compliant

with additional education. The SME/CRN inquired if nursing managers on all units would agree

to have nurses educate patients using CDC “stop the clot, spread the word” (CDC, 2020a)

handouts that would be placed in every new patient admission packet, have nurses encourage the

SCD use and passive motion exercises, and write “WEAR LEG PUMPS” (SCDs) on white

boards. The task force nursing manager took this request to the unit managers’ meeting and it

was approved to be implemented on October 19. The SME/CRN created information on VTEs,

how to educate patients using the handouts, encourage passive motions exercises, ambulation,

acceptance of anticoagulants, and writing “WEAR LEG PUMPS” on the patients white board

under the plan of care section. The clinician education was provided in power point form and

placed in the mandatory monthly online education. The SME/CRN communicated with

managers and directors via an email with a paragraph to share at nursing shift change huddles


beginning on October 12, explaining the additional measures to nurses, along with a reminder to

clarify where and how prescribed SCDs should be charted in the patient medical record

(Appendix C). On the implementation date, the SME/CRN created colorful posters and put them

in every breakroom. These posters described the changes that were being made, and showed

examples of the CDC education (Appendix B).

The SME/CRN ran daily reports on all inpatients to determine if the staff were placing

prescribed SCDs on the patients, and if the nursing staff were charting SCDs correctly in the

EMR. The reports also showed how many patients were refusing to wear SCDs. The reports

were run for 12 days before the education was provided and 12 days after to determine what the

outcomes of the education were. The data report specialist also ran a report to determine how

often heparin was being refused by patients before and after the education was provided. Positive

results of the provided education are shown in Appendix A. The nursing director of the project

informed the task force that monthly walking SCD audits were being performed.

It was determined that 2017 updates to physician order sets for patient admission have

done an excellent job of capturing high risk patients that should have VTE prevention orders. A

discussion with the physician during a task force meeting showed that GSMC was using the

Caprini Risk Assessment tool for all admitted patients to determine high, medium or low risk.

This tool allows the physician to choose the appropriate prophylaxis. The Caprini Risk

Assessment is considered a first choice tool because it incorporates comprehensive risk factors

and higher sensitivities of patients who may benefit from prophylaxis (Kakkos, et al., 2016).

An improvement opportunity found by the SME/CRN was in one of the physician order

sets that populates into the instructions of the patient medical record administration. This sub-q

heparin order is for patients that have an anticipated surgery. The heparin is ordered to give


before surgery, but the order states that the heparin should not be initiated sooner than four hours

post operatively, and not be given if the patient is on heparin. This order set needed clarification

for administering nurses. The physician intent is that sub-q heparin can be given before the

surgery, but when the patient returns to their room after surgery it should not be given sooner

than four hours. The SME/CRN brought to the task force that nurses are not administering this

medication until after the patient is post-op, increasing the risk of VTE. The SME/CRN

suggested an order change for nurse clarification when administering, and also changing to state

that sub-q heparin should not be given if the patient is on Intravenous heparin. These changes

will allow the nursing staff to know when to hold or give heparin pre- and post-op. The data

analyst ran a report to see how often the heparin is being held pre-operatively. Upon

investigation of the GSMC policy for the timing of pre and post-op administration of sub-q

heparin, there was no clarification on when it should be administered. Changes to the policy and

medication administration order set were made.

The online VTE risk assessment form was previously completed by nurses every shift to

determine VTE status changes for patients. When running a report, the nurse director on the task

force determined that only one unit is still completing the VTE risk assessment form. After an

investigation, it was determined that in 2017 when the physician order sets were updated, the

physicians are now doing this assessment, eliminating the need for nurses to complete it.

Processes that are not followed were another cause of VTEs. Peripheral inserted central

catheter (PICC) lines, and central lines and ports require cleaning with chlorohexidine wipes

every 12 hours, and flushed every eight hours. The dressings on these lines require changing

every seven days. The central line-associated bloodstream infection (CLABSI) task force


completed chart audits and provided additional education, along with an improved process for

implementing daily chlorohexidine baths for patients with these lines to help prevent PEs.

Another cause of DVTs occurs when SCD pumps or SCD sleeves are not available. It

was found that every patient bed had an SCD pump attached and that the SCD sleeves were

available on all unit supply rooms. If equipment is not working correctly, a working SCD pump

can be ordered from central supply and brought to the patient room. New SCD pumps were

ordered and delivered the first week in November.

The SME/CRN participated in the GSMC poster fair to provide critical information and

education on VTEs and the QI project (Appendix D). The SME/CRN created a PowerPoint with

quiz for “The Edge”; the mandatory clinical education for the month (Appendix E). Table top

displays were placed in every nurse breakroom showing an example of correct SCD charting,

along with information for teaching patients about blood clots. Information from the task force

was shared in weekly unit newsletters. The project was also presented to the GSMC CNO and

directors in a virtual meeting using power point education. Information from the CDC for

preventing VTEs in the obstetric population was shared with the obstetric manager. Incident

reporting was encouraged for all staff, to submit errors or near misses to help with prevention.

The SME/CRN attended a CDC conference on COVID-19 thromboembolism to glean

current strategies for preventing VTEs in COVID-19 hospitalized patients. GSMC policies on

anticoagulation were analyzed for best practice. Data was collected from patient medical records

from October 1-12 (before education) and from October 19-31 (after education). After analysis

of the data, project outcomes determined that the clinician/patient education provided positive

results in all area. There was an increase in patients wearing SCDs of 9.1%, along with a

decrease in patients refusing SCD use of .9%. There was also improvement in the charting of


SCDs. There was an increase in charting that SCDs have been ordered of 6.6%, and an increase

that SCDs have not been ordered of 1.9%. An increase that SCDs order field is not blank of

4.4%, an increase that SCDs are off patient of 1.7% and an increase that SCDs on/off field is not

blank of 2.13%.

The QI project lead to less errors in VTE prophylaxis administration, better education for

nurses and patients, clarification of order sets for physicians and nurses, policy updates,

anticipated increase in patient satisfaction, and anticipated saving of hospital resources, which

leads to increased profitability. Better SCD pumps were placed in patient rooms. The best key

indicator of evaluating project success was no patient readmissions for VTE, and no hospital

acquired VTEs after project implementation.

One issue encountered was the difficulty of running reports to extract data from the

medical records. A major issue was the nurse managers did not relay information to charge

nurses on the education, information for shift huddles, or the handouts to be placed in all patient

admission packets. The CME/CRN had to provide this information directly to the charge nurses.

Use of Informatics Technology

Informatics technology was used to participate in task force meetings due to COVID-19

restrictions. Outcomes were measured using data and reports from patient information gleaned

from electronic medical records, national data for GSMC, and scorecards. Computerized

physician order entry sets were reviewed for patients requiring VTE prophylaxis. Nurse charting

in medical records was reviewed for inconsistencies on charting the use of VTE prophylaxis. A

review of the current usage of the computerized VTE risk assessment was completed to

determine if this assessment still needed to be completed by the nurse. Informatics was also used

for plan presentation to management, and education for clinical staff.


Quality Improvement Project – Future Direction

The QI project made great strides in preventing VTEs since the last hospital acquired

DVT in August. The task force worked well together and should continue to meet monthly to

review VTE scorecards. Compliance audits should continue on inpatient units. Educators should

keep abreast of current EBP to prevent VTEs, and provide education to clinical staff annually,

and as needed. Nurses need to be proactive in educating patients to take the initiative to

ambulate, hydrate, wear SCDs, administer injectable medications, care for PICC lines and ports,

and become an active participant in their plan of care. These initiatives will lead to less VTEs,

less readmissions and increased patient satisfaction.

To promote high reliability, clinicians should be encouraged to report errors or “near

misses” in the processes to prevent VTEs. Physicians can help by using due diligence on their

VTE assessments when admitting patients to curtail serious safety issues. Before discharge,

patients should be re-educated on VTE risks, and proper anticoagulation therapy should be

prescribed, with the patient participating in a teach-back to confirm understanding.

Conclusion

VTEs continue to be a serious safety issue facing patients in the hospital and recently

discharged. Continually improving strategies for VTE prevention will help clinicians better

protect patients. A task force with a transformational leadership style was an imperative part of

this QI project, and engaging clinical staff and patients ensured success. Interactions were

needed with more disciplinary areas than was realized by the CME/CRN at the beginning of the

project. RCA (see Appendix F) and FMEA (see Appendix G) helped the CME/CRN to analyze

the opportunities that needed to be implemented to prevent VTEs. VTE risk level tables and

evidence-based practice was reviewed and helped clinicians employ best practices. Instituting


additional education for clinicians and patients was used to decrease VTEs. Changes to

processes, medication administration records and policies were changed. Nurses were able to

provide anticoagulation and SCDs to patients more frequently, and patients became more active

participants in their plan of care to reduce VTEs. The most positive results were no DVTs were

acquired at the hospital after implementation. These results will drive the future for continuous

quality improvement.


References

Agency for Healthcare and Quality (2016). Preventing hospital-associated venous

thromboembolism: A guide for effective quality improvement.

https://www.ahrq.gov/sites/default/files/publications/files/vteguide.pdf

American Heart Association (2020). Understand your risk for excessive blood clotting: Other

factors. https://heart.org/en/health-topics/venous-thromboembolism/understand-your-risk-

for-excessive-blood-clotting.

Beresford, L. (2012). Banner Good Samaritan battles VTE in real time. The Hospitalist.

https://www.the-hospitalist.org/hospitalist/article/125233/patient-safety/banner-good-

samaritan-battles-vte-real-time

Centers for Disease Control (CDC) (2020a).Venous thromboembolism: Understanding blood

clots. https://www.cdc.gov/ncbddd/dvt/understanding-blood-clots-infographic.html

Centers for Disease Control (CDC). (2020b).Venous thromboembolism: Healthcare-associated

venous thromboembolism. https://www.cdc.gov/ncbddd/dvt/ha-vte.html

Cipriano, P. (2008). Improving healthcare with systems thinking. American Nurse Today, 3(9).

https://www.myamericannurse.com/improving-health-care-with-systems-thinking/

Cohen, A., Tapson, V., Bergmann, J. (2008). Venous thromboembolism risk and prophylaxis in

the acute hospital care setting: (ENDORSE study): A multinational cross-sectional study.

Lancet, 37(9610), 387-94. doi: 10.1016/S0140-6736(08)60202-0

D'Alesandro M. (2016). Focusing on lower extremity DVT. Nursing, 46(4), 28–36.

https://doi.org/10.1097/01.NURSE.0000481417.73469.00

El-SayedEad, D., Kamelia, F., Abd-Allah, O., Hegazi, M., & Mohammed, S. (2017). Effect of

nursing care standards for preventing deep vein thrombosis among patients undergoing

https://doi.org/10.1097/01.NURSE.0000481417.73469.00

https://www.the-hospitalist.org/hospitalist/article/125233/patient-safety/banner-good-samaritan-battles-vte-real-time

https://www.the-hospitalist.org/hospitalist/article/125233/patient-safety/banner-good-samaritan-battles-vte-real-time


hip surgery on nurses' performance and patients' outcome. IOSR Journal of Nursing and

Health Science, 6(1), 51-62. doi:10.9790/1959-0601025162

Felder S., Rasmussen MS., & King R., (2019). Prolonged thromboprophylaxis with low

molecular weight heparin for abdominal or pelvic surgery. Cochrane Database of

Systematic Reviews. doi:10.1002/14651858.CD004318.pub4

Frandsen, B. (2015). Servant leadership: Leadership style defined. American Association of

Nurse Association of Nurse Assessment Coordination.

https://www.aanac.org/Information/FAQs/post/servant-leadership-leadership-style-

defined/2012-02-20

Good Samaritan Medical Center. (2019) (GSMC PSI-12 Coding Data)

Ibrahim, M., Ahmed, A., Mohamed, W., & El-Sayed Abu Abduo, S. (2015). Effect of

compression devices on preventing deep vein thrombosis among adult trauma patients: A

systematic review. Dimensions of Critical Care Nursing, 34(5), 289‐300.

doi:10.1097/DCC.0000000000000127

Joint Commission. (2019). Specifications manual for national hospital inpatient quality

measures. https://www.jointcommission.org/-/media/tjc/documents/measurement/

specification-manuals/hiqr_specsman_july2019_v5_6.pdf

Kakkos S., Caprini J., & Geroulakos G. (2016). Combined intermittent pneumatic leg

compression and pharmacological prophylaxis for prevention of venous

thromboembolism. Cochrane Database Syst Rev. 2016; 9(9):CD005258.

doi:10.1002/14651858.CD005258.pub3

King, I.M. (1989). Health as a goal for nursing. Nursing Science Quarterly, 3(3), 123-128.

https://doi.org/10.1177/089431849000300307


Middeldorp, S., Coppens, M., Van Haaps, T., et. al. (2020). Incidence of venous

thromboembolism in hospitalized patients with COVID-19. Journal of thrombosis and

haemostasis. https://pubmed.ncbi.nlm.nih.gov/32369666/

National Surgical Quality Improvement Program (2018). Participant Use Data File.

https://www.facs.org/quality-programs/acs-nsqip/participant-use

Sherwood, G., & Barnsteiner, J. (2017). Quality and safety in nursing: A competency approach

to improving outcomes (2nd ed.). John Wiley & Sons.

Smith, J. (2020). Preventing venous thromboembolism in the inpatient population.

Streiff, M., Carolan, H., Hobson, D., Kraus, P., Holzmueller, C., Demski, R., Lau, B., Biscup-

Horn, P., Pronovost, P., & Haut, E. (2016). The Johns Hopkins VTE collaborative.

Journal of Hospital Medicine. doi:10.1002/jhm.2657

The Leapfrog Group (2020). Leapfrog hospital safety grade: Good Samaritan Medical Center.

https://www.hospitalsafetygrade.org/h/good-samaritan-medical-center-lafayette-co?

findBy=city&city=Lafayette&state_prov=CO&rPos=200&rSort=distance

U.S. Department of Health and Human Services. (2008). Surgeon General’s call to action to

prevent deep vein thrombosis and pulmonary embolism.

https://www.ncbi.nlm.nih.gov/books/NBK44178/

United States Office of the Surgeon General: National Heart, Lung, and Blood Institute. (2008).

The Surgeon General's call to action to prevent deep vein thrombosis and pulmonary

embolism. Rockville (MD): https://www.ncbi.nlm.nih.gov/books/NBK44178/

Appendix A

Patient SCD use before and after education

https://www.hospitalsafetygrade.org/h/good-samaritan-medical-center-lafayette-co?findBy=city&city=Lafayette&state_prov=CO&rPos=200&rSort=distance

https://www.hospitalsafetygrade.org/h/good-samaritan-medical-center-lafayette-co?findBy=city&city=Lafayette&state_prov=CO&rPos=200&rSort=distance

https://www.facs.org/quality-programs/acs-nsqip/participant-use


Clinician/Patient education provided positive results in all areas

Increased use of SCDs on patients legs by 9.1%Decrease in patients refusing SCDs by .9%

29.4

54.2

11.9

SCD Use Before Education(October 1-12, 2020)

SCDs off and/or refusedSCDs both on or one on

26.7

63.3

9.77

SCD Use After Education(October 19-31, 2020)

SCDs off and/or refused

SCDs both on or one on

Correct SCD Charting before and after education

Clinician/Patient education provided positive results in all areas


Increased correct charting that SCDs have been ordered 6.6%Increased correct charting that SCDs have not been ordered 1.9%Increased correct charting that SCDs order field is not blank 4.4%Increased correct charting that SCDs are off patient 1.7%Increased correct charting that SCDs on/off field is not blank 2.13%

74.6

16.2

9.1

SCD Charting Before Education(October 1-12, 2020)

SCDs ordered? Charted: YesSCDs ordered? Charted: No

81.2

14.34.7

SCD Charting After Education(October 19-31, 2020)

SCDs ordered? Charted: Yes

SCDs ordered? Charted: No

Appendix B

Implementation VTE Prevention Roll-Out Poster Boards


Appendix C

Huddle information for all Inpatient Units


Please share with your clinical staff. The VTE initiative starts Monday, October 19th.

The VTE prevention task force along with the inpatient Unit Managers have approved an initiative to include CDC blood clot information in admission packets for nurses to share with patients. Also approved was the initiative to write "WEAR LEG PUMPS" on the patient white board. The Edge Education included a Powerpoint explaining this important initiative to staff.

Below is the note that was to be shared in shift huddles starting October 12th:

We have an opportunity to help decrease DVTs! Starting on October 19th, nurses will be provided with CDC “Stop the Clot, Spread the Word” handouts in admission packets. The handouts can be used to help educate our patients on blood clots. We want to stress the importance of wearing SCDs at all times except when ambulating, and the importance of accepting heparin and lovenox injections. CNAs and RNs will also be writing “WEAR LEG PUMPS” on the white board to remind patients to wear their SCDs. We believe that by involving the patient in their plan of care, they will be more likely to participate, and keep themselves safe from DVTs.

As a reminder, if a patient has SCDs ordered, the ADL charting for VTE Mechanical Prophylaxis should be YES. Congratulations on helping to prevent DVTs!

Some initial CDC handouts have been paper clipped to this note to help the units get started putting them into the admission packets.

Appendix D

Poster Completed for Annual Poster Fair


Appendix E


Sample of slides from the mandatory monthly Edge education Powerpoint

Appendix F


Root Cause Analysis (Fish Bone Diagram)

Appendix G

Failure Mode and Effects Analysis


Process Step

Failure Mode

Effect Sev.1-3

Cause Controls Prob 1-3

RiskIndex

Recommended Actions

Decrease rates of VTEs for inpatient population at Good Samaritan Medical Center

No decrease of VTEs or increase in VTEs

Patient acquires hospital VTE.

3

Correct prevention strategies not ordered or administered.

Prevention orders based on reason for admission, comorbidities, ambulatory status. Nurses follow orders, protocols for VTE prevention.

Review physician computer order sets for completeness. Educate nurses on VTE importance and the appropriate VTE needed for different conditions/surgeries.Track use of VTE in patient chart: Is it being administered? Encourage nurses to enter errors found in error reporting software so reasons for fall-outs can be corrected.

Patient not compliant with discharge instructions.

Education provided to patients on VTE prevention and risks, in easy to understand format.

Educate patients at admission, administration of VTE prevention and at discharge. Stop the Clot, Spread the word user friendly.

Patient acquires VTE after discharge and has to be readmitted

Patients upset about re-admittance for the same problem, loses confidence in hospital system

Re-education of risks and prevention of VTE, apology and transparent discussion of why this could have happened

Educate patients on VTEs during administration of VTE prevention and at discharge.

Patient in pain again.

Control pain adequately.

Control pain using medications and other measures to keep the patient comfortable.

Patient acquires VTE after discharge and has to be readmitted

3

Hospital loses money due to HCAHPS scores/readmissions for the same issue.

Better strategies for VTE prevention Apology to patient to increase score in spite of Patient dissatisfaction

Hospital works on better prevention plan and education to decrease VTEs. Patient satisfaction group works with patient to minimize poor patient satisfaction scores

Cost of staff, equipment, room, supplies.

Educate staff on VTE prevention, controls to prevent fall-outs.

Educate staff on order sets, VTE prevention, controls to prevent fall-outs.


Appendix H

MSN Student GSMC Clinical Nurse Champion Award

We are thrilled to announce our Clinical Nurse Quality Champion Joy Smith (for her work on deep vein

thrombosis)! Thank you Joy, for all you do for our patients and the nursing profession! (October 13, 2020)

Picture of my manager, my preceptor and me.

Documents

joysmithportfolio.weebly.com · Web viewThe root causes for VTEs were identified and acted on with education for clinicians and patients. ... (DVT) is a significant health issue,