1 st 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 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.”

Know Risk Factors Caprini (surgical patients) Age 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 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 Age ≥ 75 y Hx of VTE Family Hx of VTE Factor V Leiden Prothrombin 20210A Lupus anticoagulant Anticardiolipin antibodies Elevated serum homocysteine Heparin-induced thrombocytopenia Other congenital or acquired thrombophilia 3 Stroke (< 1 mo) Elective arthroplasty Hip, pelvis or leg fracture Acute 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 (9 th Ed) Evidence-based clinical practice guidelines and Chest (2 suppl) VTE Prevention in…… Acutely ill hospitalized medical patients (Kahn SR et al. Chest :(2_suppl):e195s-226s) Non-orthopedic surgical patients (Gould MK et al. Chest (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:  Resource Center  Disease State Management  VTE Prevention and Treatment

From: University of Washington Access on:  Resource Center  Comprehensive Toolkitswww.excellence.acforum.org

This pocket guide can be accessed on  Resource Centerwww.excellence.acforum.org

From: University of Washington Access on:  Resource Center  Comprehensive Toolkitswww.excellence.acforum.org

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:

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?

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

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 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:

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? 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: – Human alerts (Piazza et al. Circulation. 2009: ) 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):

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?