1 st Qatar Conference on Safe Anticoagulation Management: New Advances & Trends Hospital Acquired VTE: Input of Nurse February 27, 2015 Lynn B. Oertel,

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?