venous thromboembolism vte a preventable · pdf filevenous thromboembolism “vte”:...

Venous Thromboembolism

“VTE”:

A Preventable Problem

NoCVA Safe Surgery Collaborative August 19, 2013

Sharon McNamara, MSN, RN, CNOR

Erica Preston-Roedder, PhD, MSPH, Director of Quality Meaurement, NCQC

1

NoCVA Safe Surgery

Collaborative Goals

• Reduce post-surgical DVT and PE rates by 40% from the 2011 baseline.

• Reduce SSI SIR for COLO and HYST procedures by 40% compared to Q1-Q2 2012.

• 3% improvement in dimension scores on the Surgical Safety Culture Survey (Safe Surgery 2015)

• 80% completion of observation tools , using the standard observation instruments provided by the collaborative.

Collaborative Tools and Strategies

• Brief teamwork training customized to OR

• Implementation of the NoCVA Surgical Safety Checklist or derivative

• Observational assessment of checklist use and teamwork behaviors

• Defect analysis of events

• Process for gathering issues from debriefing and using that info for improvement

• Executive safety rounding

• Safety culture assessment

Post-surgical VTE (PSI 12)

• AHRQ PSIs are a series of claims-based indicators for patient safety

• PSI #12 = Post-surgical VTE

• Definition on AHRQ website:

http://www.qualityindicators.ahrq.gov/Modules/PSI_TechSpec.aspx

• Risk factors for adjustment found at:

http://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V45/Parameter_Estimates_PSI_45.pdf





PSI 12

Patients w/PE or DVT which is not present on admission

(excludes vena cava & MDC 14)

------------------------------------------

Surgical patients

Numerator (case definition)

• Numerator: Any patient with a DVT or PE

• ICD-9-CM Deep vein thrombosis diagnosis codes:

• 45111 FEMORAL VEIN PHLEBITIS

• 45119 DEEP PHLEBTIS-LEG NEC

• 4512 THROMBOPHLEBITIS LEG NOS

• 45181 ILIAC THROMBOPHLEBITIS

• 4519 THROMBOPHLEBITIS NOS

• 45340 AC DVT/EMBL LOW EXT NOS

• 45341 AC DVT/EMB PROX LOW EXT

• 45342 AC DBT/EMB DISTL LOW EXT

• 4538 VENOUS THROMBOSIS NEC

• 4539 VENOUS THROMBOSIS NOS

• ICD-9-CM Pulmonary embolism diagnosis codes:

• 4151 PULMON EMBOLISM/INFARCT

• 41513 SADDLE EMBOL PULMON ART

• 41511 IATROGEN PULM EMB/INFARC

• 41519 PULM EMBOL/INFARCT NEC

Denominator (Population)

• Denominator: All surgical patients

• Exclude cases:

• with a principal ICD-9-CM diagnosis code (or secondary diagnosis present on admission)

for deep vein thrombosis (see above)

• with a principal ICD-9-CM diagnosis code (or secondary diagnosis present on admission)

for pulmonary embolism (see above)

• where the only operating room procedure is interruption of vena cava

• where a procedure for interruption of vena cava occurs before or on the same day as the

first operating room procedure

• MDC 14 (pregnancy, childbirth, and puerperium)

• with missing gender (SEX=missing), age (AGE=missing), quarter (DQTR=missing), year

(YEAR=missing), or principal diagnosis (DX1=missing)

NOTE: If you are not coding POA, this will affect your rates by ~110%! (HCUP study)

Venous Thromboembolism

“VTE”

A Preventable Problem

“Pulmonary embolism “PE” resulting from deep vein thrombosis “DVT” collectively referred to as Venous Thromboembolism is the most common preventable cause of hospital deaths.”

Preventing hospital-acquired venous thromboembolism: a guide for effective quality improvement. Agency for Healthcare Research and Quality. 2007

Relevance in USA

• 2 Million Patients suffer VTE annually

• Half develop VTE in hospital or 30 days post hospital

• Most hospitalized patients have at least one risk factor for VTE

• 23 Million surgeries performed annually

• 20% of patients in high risk category (ie. Hip & knee arthroplasty, hip fractures) develop proximal DVTs

• Proximal DVT is most dangerous and frequently lead to PE without anticoagulant prophylaxis

• One in ten surgical patients develop a DVT and go on to die from a PE = 20,000 patients yearly, this represents more deaths than those from breast cancer, AIDS, and traffic accidents combined.

Preventing hospital-acquired venous thromboembolism: a guide for effective quality improvement. Agency for Healthcare Research and Quality. http//www.ahrq.gov/QUAL/vtguide/. Accessed July 2, 2013.

Cost Estimates

• Increases cost in treatment and length of stay

• DVT = $10,000

• PE = $20,000

Preventing hospital-acquired venous thromboembolism: a guide for effective

quality improvement. Agency for Healthcare Research and Quality. http//www.ahrq.gov/QUAL/vtguide/. Accessed July 2, 2013.

VTE

Primary Causative

Factors

• Venous stasis

• Vessel wall injury

• Hypercoagulability

Ahoen J. Day surgery and

thromboembolic complications: time for

structured assessment and prophylaxis.

Curr Opin Anaesthesiol.

2007;20(6):535-539.

Risk Factors

• Immobility

• Tissue Trauma

• Surgical positioning

requirements

Rawat A, Huynh TT, et al. Primary

prophylaxis of venous thromboembolism

in surgical patients. Vas Endovascular

Surg. 2008;42(3):205-216.

12

AORN Recommended

Practices for Prevention of

Deep Vein Thrombosis

Recommended Practices for Prevention of Deep Vein Thrombosis. Perioperative Standards and Recommended Practices For Inpatient

and Ambulatory Settings. 2013 Edition: 365-374.

I. A healthcare organization wide PROTOCOL for the

prevention of DVT that includes care of the

perioperative patient should be developed and

implemented.

• Developed by a multidisciplinary team

• Supported by evidence-based model (risk based, group specific)

• Accessible to all healthcare providers

• Contain links to evidence-based treatment options

• Provide alternatives to suggested treatment

• List contraindications

• Simple to apply

• Apply to all patients within the health care organizations scope of service

II. The perioperative RN should complete a

PERIOPERATIVE PATIENT ASSESSMENT to determine

DVT RISK FACTORS.

Venous Stasis:

• Age > 40 years (>50 years)

• Cancer & associated therapy

• Cardiac disease history (CHF &

MI)

• Obesity

• Pregnancy & postpartum period

• Prolonged bed rest or

immobilization

• Prolonged travel (4-10 hours in

previous 8 weeks)

• Surgery > 30 minutes

• Varicose veins

Vessel Wall Injury:


• Central venous catheters

• Extensive burns

• Previous history of VTE or

stroke

• Surgery

• Trauma

Additional Risk Factors

Hypercoagulability:


• Inherited or acquired

thrombophilia

• Oral contraceptive use of

hormone replacement

therapy

• Pregnancy and the

postpartum period

• Trauma

Other:

• Acute medical illness

• Acute infectious processes

• Inflammatory conditions

• Smoking

• Dehydration

• Inflammatory bowel disease

• Active rheumatic disease

• Sickle cell disease

• Acute & chronic lung diease

III. The perioperative RN should IMPLEMENT SPECIFIC INTERVENTIONS when the

patient is receiving MECHANICAL DVT PROPHYLAXIS.

• Early ambulation

• Active & passive foot & ankle exercises

• Use of graduated compression stockings

• Intermittent pneumatic compression devices

Contraindications & Possible

Complications in Mechanical DVT

Prophylaxis

Contraindications

1. Conditions affecting lower extremities

2. Conditions compromising lower extremity venous flow

3. Sensitivity to latex, unless wraps & tubing are latex free

4. Severe congestive heart failure

5. Thigh circumference exceeds limit of manufacturers directions for use

Complications

1. Compartment syndrome

2. Latex sensitivity or allergy

3. Peroneal nerve injury/palsy

4. Skin injury

IV. The perioperative RN should IMPLEMENT SPECIFIC

INTERVENTIONS when the patient is receiving

PHAMACOLOGIC DVT PROPHYLAXIS.

Contraindications

1. Complex trauma

2. Hemorrhage

3. Infective endocarditis

4. Neurosurgery

5. Ocular surgery

6. Preganacy

7. Recent intracranial, gastric,

GU bleeding

8. Recent surgery

9. Recent lumbar/neuraxial

anesthesia (24 hours)

Complications

1. Bleeding

2. Compartment syndrome

3. Hematoma formation

4. Heparin induced

thrombocytopenia

5. Osteoporosis & osteopenia

6. Skin neucrosis

7. Thrombocytopenia

8. Urticaria at injection site

Develop Adequate

Prophylaxis Regimens

for Each Level of VTE

Risk

Following table taken from an audit tool not intended to

be used for order sets or protocols

Low Risk Moderate Risk High Risk

Early

ambulation

Heparin 5,000 units SC q 8 h or Dalteparin 5,000 units

SC daily or

Heparin 7,500 units SC q 12 h or Enoxaparin 30 mg SC q

12 hours or

Dalteparin 5,000 units SC daily or Enoxaparin 40 mg SC q

day or

Enoxaparin 40 mg SC daily or

Heparin 5,000 units SC q 12 hours

(only for patients with weight <50

kg

or age >75 years)

Fondaparinux 2.5 mg SC

daily or

Suggest adding SCD’s

Warfarin, INR 2-3

Add SCD’s (unless not

feasible)

Preventing hospital-acquired venous

thromboembolism: a guide for effective quality

improvement. Agency for Healthcare Research and

Quality. (Appendix D Chart Audit Form)

Table taken from audit tool not

intended to be used for order

sets or protocols

Cape Fear Valley Health

Dana Jackson, PharmD, BCPS

Clinical Informatics Pharmacist

Marcia Smith, RN, BSN

Nursing Quality Coordinator

22

Cape Fear Valley Health System

23

V. The perioperative RN should PROVIDE THE PATIENT

AND HIS OR HER DESIGNATED CAREGIVER(S)

INSTRUCTIONS regarding prevention of DVT and the

prescribed prophylactic measures.

Mechanical

• Mechanism of mechanical prophylaxis

• Importance of compliance

• Wearing properly sized graduated compression stockings (GCS)

• Application, removal & reapplication of GCS

Pharmacological

• Follow-up MD appointments and lab work

• Continuing medications

• Avoid activities that may cause injury

• Do not use over-the-counter medications (eg, aspirin, ibuprofin)

• Aware of medication & food interactions

• Use soft toothbrush, electric razor

• Report bruising

• Inform dentist, lab tech re VTE prophylaxis

Patient & Family Education &

Engagement Should Include

1. Current & future risk factors

2. Maintaining adequate hydration

3. Common signs & symptoms of DVT & PE

4. Avoid constrictive clothes

5. Avoid sitting with legs crossed, knees bent or standing, sitting for long periods

6. Elevate legs when sitting

7. Perform passive & active exercise (lower extremities)

8. Comply with VTE Prophylaxis

9. Perform frequent coughing & deep breathing exercises while in bed

10. Physiology of blood flow & clot formation

VI. PERSONNEL should receive INITIAL EDUCATION & COMPETENCY VALIDATION, as applicable to their roles, on patient care measures to prevent DVT.

VII. DOCUMENTATION should include a patient assessment, plan of care, nursing diagnosis, identification of desired outcomes and interventions, as well as an evaluation of the patient’s response to care.

VIII. POLICIES AND PROCEDURES for DVT prophylaxis should be developed, reviewed periodically, revised as necessary, and readily available in the practice setting.

IX. A QUALITY IMPROVEMENT PROGRAM should be in place to evaluate the outcomes of DVT prophylaxis and protocol compliance.

Agency for Healthcare Research and Quality.

(AHRQ) Recommendations

.

1. QI Program should include a study time frame

2. Compare the HCO DVT prevention protocol (PP) to current research & established, research based guidelines

3. Determine the HCO DVT PP rate of use

4. Determine & explore barriers to the use of the protocol

5. Determine the rate of readmissions for DVT or complications related to DVT

Preventing Hospital-Acquired Venous Throboembolism A Guide for Effective Quality Improvement. See Appendix D Chart Audit Form

29

Venous Thromboembolism Event Report Tool for Defect Analysis

Developed by Johns Hopkins University. Adapted by:

Patient: MR No: Admit Date:

Diagnosis: Date of VTE Event:

Date this Report Completed

Type of VTE

Location (Unit) Where Occurred

Patient Information and VTE Prevention Practices

1 Patient’s location/room number(s) since admission.

2 List VTE risk factors on admission.

3 Was there a documented VTE risk assessment at the time of admission by

a provider?

Yes: __________

No: ___________ If no, please explain___________________________________

4 Did provider order appropriate VTE prophylaxis at admission? Yes: __________

No: ___________ If no, please

explain___________________________________

5 Was VTE prophylaxis delivered/administered appropriately, by hospital policy, as ordered and in a timely manner?

Yes: __________ No: ___________ If no, please explain

why:_________________________________________

6 Were VTE risk factors assessed at regular intervals during time patient was an inpatient?


why:__________________________ _________

7 Are there standard protocols for VTE prophylaxis in the facility for use in this patient population?

Yes:____________ No:____________ If no, should there be?

8 If a VTE protocol was in place, is it up-to-date and evidence-based? Yes: ____________ No:______________ If no, please explain:

9 Have there been any issues at the facility interfering with compliance to VTE protocols such as equipment issues? Drug back-orders? Drug-shortages? Etc.?

No:___________ Yes: ________________ If yes, please explain:

10 Was VTE prophylaxis stopped or held for any reason prior to the VTE

event?

No:_____________ Yes: ________________If yes, please

explain and provide location in which it was suspended and for

how long:

11 What education was provided to the patient and family on VTE prevention

upon admission or identification of at-risk status?

12 Were VTE prophylaxis protocols embedded in admission /routine/transfer orders or are they add-ons?

Embedded: Admission? ___________ Transfer?_______________

Add-on:_________________________

13 Is there a standardized VTE risk assessment immediately available on admission and during stay to promote frequency and consistency in

assessments?

Yes:_______________ No:________________ If no, please explain:

14 Are VTE assessments and related reminders embedded in hand-off communications?


why:________________________________

15 How are VTE protocols enforced? (Hard stops? Flags? Etc.?)

16 Have someone do a gemba walk (walk the process observing for protocol adherence) on each unit in which the patient was cared for, assessing 5

patients on each of those units for VTE protocol adherence. Discuss

findings.

17 What are the facility rates for VTE? Which units have the highest rates? Which patient populations?

18 Can each staff member involved in this patient’s care verbalize correct strategies to prevent VTE?

19 Are there any significant patient factors that may have contributed to this event?

Yes: _______ Please explain why: No: ________ Please explain why:

20 After your assessment, do you believe this event was potentially

preventable?

VTE Resources

Ahoen J. Day surgery and thromboembolic complications: time for structured assessment and prophylaxis. Curr Opin

Anaesthesiol. 2007;20(6):535-539.

Eisenstein D. Anticoagulation Management in the Ambulatory Surgical Setting. AORN Journal. 2012;95(4): 510-524.

Rawat A, Huynh TT, et al. Primary prophylaxis of venous thromboembolism in surgical patients. Vas Endovascular

Surg. 2008;42(3):205-216.

Recommended Practice for Prevention of Deep Vein Thrombosis. AORN Perioperative Standards and Recommended

Practices For Inpatients and Ambulatory Settings. AORN 2013: 365-373.

Partnership for Patient Care. Failure mode and effects analysis venous thromboembolism prophylaxis. ECRI Institute

Healthcare Improvement Foundation. 2007.

https://www.ecri.org/Documents/Patient_Safety_Center/PPC_VTE_Prophylaxis.pdf. Accessed 7/2/13.

Preventing Hospital-acquired venous throboembolism a guide for effective quality improvement. Agency for Healthcare

Research and Quality. www.ahrq.gov/.../quality-patient-safety/patient-safety-

resources/resources/vtguide/vtguide.pdf - 312k - 2013-06-18. Accessed 7/3/13.

Venou tromboembolism prophylaxis in orthopedic surgery. Effective Health Care Program Comparative Effectiveness

Review #49. Agency for Healthcare Research and Quality.

http://www.effectivehealthcare.ahrq.gov/ehc/products/186/992/CER-49_VTE_20120313.pdf. Accessed 6/12/13.

Venous thromboembolism in adult hospitalizations – united states 2007-2009. Morbidity and Mortality Weekly Report.

2012;61(22):401-404.

Guyatt GH, Crowther M, Gutterman DD, etal. Antimicrobial therapy and prevention of thrombosis, 9th ed. American

college of chest physicians evidence-based clinical practice guidelines.

http://journal.publications.chestnet.org/data/Journals/CHEST/23443/1412S3.pdf. Accessed 7/8/13.

https://www.ecri.org/Documents/Patient_Safety_Center/PPC_VTE_Prophylaxis.pdf

http://www.ahrq.gov/.../quality-patient-safety/patient-safety-resources/resources/vtguide/vtguide.pdf%20-%20312k%20-%202013-06-18



















http://www.effectivehealthcare.ahrq.gov/ehc/products/186/992/CER-49_VTE_20120313.pdf



http://journal.publications.chestnet.org/data/Journals/CHEST/23443/1412S3.pdf

Next Steps

Learning from Defects homework September 16

Webinar: Learning from Defects

Case Study and Report Out

September 16

1:00

Learning Session 2:

Chapel Hill, NC

October 2

Webinar: Executive Partnerships:

Walkrounds

October 26 1:00

Invite your Executive Sponsor

Continue implementing checklist

and completing observations

Continue teamwork training

Project Contacts

Laura Maynard, MDiv

Director of Collaborative Learning

[email protected]

919-677-4121

Jan Mangun, MT(ASCP), MSA, CPHRM

Exec Director, Quality and Pt. Safety, VHHA

[email protected]

804-965-1202

Erica Preston-Roedder, PhD, MSPH

Director of Quality Measurement

[email protected]

919-677-4125

Dean Higgins, BA

Project Manager

[email protected]

919-677-4212

James Hayes

Project Coordinator

[email protected]

919-677-4140

mailto:[email protected]



