Transcript Slide 1

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, CACP
Nursing Practice Specialist
Anticoagulation Management Service
Massachusetts General Hospital, Boston, MA, USA
Seek nurse input to influence:
• Awareness
• Education of workforce
Individual level
• Establish a plan and
collaborate with a
multidisciplinary team
• Re-evaluate process –
where are the gaps?
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 Factors
Caprini (surgical patients)
Padua Prediction Score
(medical patients)
Age 41-60 y
Minor Surgery
BMI > 25
Swollen legs
Varicose veins
Pregnancy or postpartum
Hx unexplained/recurrent
abortion
Oral contraceptive or hormone
replacement
Sepsis (<1 mo)
Serious lung disease
Abnormal pulmonary function
Congestive heart failure (<1 mo)
Hx of inflammatory bowel
disease
Medical patient at bed rest
1
Age 61-74 y
Arthroscopic surgery
Major open surgery (>45 min)
Laparoscopic surgery (>45 in)
Malignancy
Confined to bed (>72 h)
Immobilizing plaster cast
Central venous access
2
Anticardiolipin antibodies
Elevated serum homocysteine
Heparin-induced
thrombocytopenia
Other congenital or acquired
thrombophilia
3
Hip, pelvis or leg fracture
Acute spinal cord injury (< 1 mo)
5
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
Age ≥ 75 y
Hx of VTE
Family Hx of VTE
Factor V Leiden
Prothrombin 20210A
Lupus anticoagulant
Ongoing hormonal treatment
1
Stroke (< 1 mo)
Elective arthroplasty
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
VTE Preventionclinical
in……
practice guidelines and
• 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)
Chest 2012. 141(2 suppl)
www.chestjournal.org
Access via: www.excellence.acforum.org
 Resource Center  Disease State Management  VTE Prevention and Treatment
From: University of Washington
Access 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 Washington
Access 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
The IMPROVE Registry
(International Medical
Prophylaxis Registry on Venous
Thromboembolism)
• Prospective cohort of
hospitalized medical patients
• 11 countries
• Risk calculators for web or
iphone
http://www.outcomes-umassmed.org/IMPROVE/
How best to make a difference with
VTE prophylaxis?
Multidisciplinary TEAM
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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
• 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
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
Approaches:
1) Opt out approach
2) No VTE risk assessment model
3) Buckets of Risk
4) 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 assessment
2) Menu of evidence-based options for prophylaxis
3) 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?
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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?