Vte prophylaxis

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PROPHYLAXISCyrena De RamosSt. Cloud State UniversityNovember 12, 2014IMPROVINGVENOUS THROMBOEMBOLISM (VTE)1

Learning ObjectivesUnderstand data supporting the significance of VTE prophylaxis for medical patientsRecognize 3 core measures related to VTE prophylaxisUnderstand correct use and contraindications for pharmaceutical VTE prophylaxisUnderstand correct use, fit, and contraindications for mechanical VTE prophylaxisIdentify various ways to improve patient compliance/use of VTE prophylaxis2

Data on Hospital Acquired VTEVTE comprising pulmonary embolism(PE) and deep vein thrombosis (DVT), accounts for 5% - 10% of all deaths among hospitalized patientsDVTs affect as many as 600,000 patients annuallyPEs are recognized as the most common cause of preventable hospital deaths and account for up to 200,000 deaths annually.10% to 20% of medical patients acquire DVTsOnly 40% of at-risk medical patients receive guideline recommended VTE prophylaxisCMS considers VTE in hospitalized patients a never event, which is pegged to the pay for performance initiative

VTE prophylaxis is an essential patient safety practice and one that can prevent in hospital death

200,00 deaths annually refers to the US only

Virchows classic description of factors basic toVTE included stasis or reduction in blood flow, vesselinjury, and hypercoagulability. IPC devices arethought to reduce DVT risk by increasing the velocityof venous blood flow and by stimulating regionalfibrinolytic activity.7

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VTE Prophylaxis Statistics60% of DVTs and 50% of PEs could be avoided with proper use of VTE prophylaxis100,000 lives could be saved annually with proper use of VTE prophylaxis360,000 individuals would avoid the negative consequences of DVTsNegative consequences PainSwelling of extremityLost time from work/wagesVenous stasis leads to ulcers, chronic skin and bone infections (Results from irreversible damage to valves in veins)Vericose veins4

VTE Prophylaxis Core MeasuresVTE-1

Venous Thromboembolism Prophylaxis

VTE-2

Intensive Care Unit Venous Thromboembolism Prophylaxis

VTE-3

Venous Thromboembolism Patients with Anticoagulation Overlap Therapy

VTE-4

Venous Thromboembolism Patients Receiving Unfractionated Heparin with Dosages/Platelet Count Monitoring by Protocol or Nomogram

VTE-5

Venous Thromboembolism Warfarin Therapy Discharge Instructions

VTE-6

Hospital Acquired Potentially-Preventable Venous Thromboembolism

This is a table depicting the Joint Commission's Core Measures related to VTE prophylaxis.

As nursing staff, we must focus on Measures 1, 5, and 6

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VTE Prophylaxis Core MeasuresMeasure 1 VTE ProphylaxisAdminister Pharmaceutical Prophylaxis in a timely mannerApply and document Mechanical Prophylaxis by midnight on hospital day 2Documentation must state on or refusedMeasure 5 VTE Warfarin Therapy Discharge InstructionsWarfarin (Coumadin) teaching provided and documented prior to dischargeDocumentation must reflect literature was providedMeasure 6 Hospital Acquired potentially-preventable VTEMed 1 has had 1 instance of Hospital Acquired VTE

Weve had 30 misses care center wide since January (mostly on Onc and Med 1). Our goal percentage is 97%, we are currently at 91.4% so theres lots of room for growth.

VTE-1: physician must order appropriate prophylaxis (SCDs or heparin/lovenox or contraindications for both). Nurses must administer heparin/lovenox or apply sequentials by end of midnight on hospital day 2. Must document the sequentials as applied or refused to meet the core measure on the AID flowsheet. PCAs can be vital to this measure, Biggest miss is not documenting sequential application or refusal.VTE-5: Coumadin teaching must be provided and documented on the Teaching Record in Epic as literature. If the nurse documents explanation it does not meet the measure.VTE-6: This measure assesses the number of patients diagnosed with confirmed VTE during hospitalization (not present at admission) who did not receive VTE prophylaxis between hospital admission and the day before the VTE diagnostic testing order date. VTE is considered a never event Medicare will no longer pay the extra cost of treating VTE that occur while the patient is in the hospital.

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Pharmaceutical VTE ProphylaxisPharmacologic prophylaxis should include heparin or a related productLMWH such as Enoxaparin (Lovenox)Warfarin (Coumadin)Preferred method of VTE prophylaxis when not contraindicatedPharmacologic prophylaxis is more effective than mechanical prophylaxis Implemented unless the risk for bleeding outweighs the expected benefitContinue throughout course of hospitalization, including at discharge

Patients are still at risk for VTE when they are discharged, it is best practice to administer a final dose of Heparin or lovenox if it is due at the time of discharge to extend the patients protection. A patient may go home and rest and suffer a DVT or PE7

Correct use of Pharmaceutical VTE ProphylaxisSubcutaneous Heparin5,000 units/doseSubcutaneous injectionAdministered every 8 hours for 7 days or until patient fully ambulatory

Enoxaparin (Lovenox)40 mg/dose (30mg/dose in renal impairment)Subcutaneous injectionAdministered every 24 hours for 7-10 days, usually not more than 12 days

Warfarin (Coumadin)Up to 10 mg/dose, adjusted based on INRApproximately 5 days to reach therapeutic levelsTaken OrallyAdministered daily for 3-12 months or indefinitely

SCH administers sub-q heparin for VTE prophylaxis q8h (tid), however q12h (bid) is also an acceptable administration schedule. Bid dosing reduces the risk of bleeding complications, however tid dosing is more effective in reducing the instance of VTE.

Additional research is needed to examine the effectiveness of this dosing in obese and morbidly obese patients. The risk of obese patients (body mass index [BMI] of 30 kg/m2) suffering VTE is twice that of their nonobese counterparts. Furthermore, there is a five-fold increased risk of VTE in the morbidly obese (BMI of 40 kg/m2).

Renal impairment for lovenox dosing is CrCl less than 30mL/min Heparin: 7 days or until fully ambulatory/no longer at risk whichever is longer8

Contraindications to Pharmaceutical VTE ProphylaxisActive BleedingHigh-risk uncontrolled hemorrhage Bleeding disorders, Thrombocytopenia, and/or Conditions in which bleeding would be catastrophicRenal dysfunctionLiver disease with CoagulopathyHypersensitivity to Heparin or LMWHINR > 1.5Spinal Tap or Epidural AnesthesiaIntracranial and/or Intraocular Surgery within 6 weeksMajor Trauma/Closed Head Injury/Intracranial BleedUncontrolled Hypertension (SBP>200 mmHg, DBP> 110 mmHg)

The evidence supporting its recommendations comes from a recent multinational observational study of hospitalized medical patients for whom independent risk factors of major and nonmajor bleeding events were identified. Over 10,000 patients were evaluated, and 11 distinct risk factors were identified as being independently associated with in hospital bleeding. The 3 major risk factors were an active gastroduodenal ulcer, bleeding within the three months before hospital admission, and a platelet count of