1. Venous Thromboembolism (VTE) Etiology, Prevention, Recognition, and Treatment 1

2. Venous Thromboembolism (VTE) Venous thromboembolism (VTE) is a term used to describe a blood clot or thrombus that forms within a vein. A common site for a VTE is within deep veins also known as a deep venous thrombosis or DVT. 2

3. Deep Venous Thrombosis or DVT Deep Venous Thrombosis, or DVT, often develops in the lower extremities and/or pelvis but can occur in the upper extremities. Because DVT’s involve the deep veins, there is a direct connection to the heart and lungs. 3

4. Where is DVT Likely to Develop? 4

5. Causes of Deep Venous Thrombosis or DVT Typically DVT’s are caused by underlying conditions which may or may not be easily identified. Some of the factors that can cause a DVT include: Clotting disorders which may cause the person’s blood to clot more quickly Slow or sluggish blood flow through the veins Irritation or inflammation of the inner lining of the vein 5

6. Patients at Risk to Develop DVT Know which patients are at highest risk to develop a DVT: Prior history of DVT or PE (pulmonary embolism) Immobility for any reason Surgery patients Limb trauma and/or orthopedic procedures Coagulation abnormalities Age HRT or OCP Pregnancy Cancer Obesity Smoking Endothelial damage 6

7. Preventing DVT Utilize a standardized VTE risk assessment Develop and implement a standardized VTE prophylaxis order set to include a list of contraindications to pharmacologic VTE prophylaxis Incorporate standardized VTE prophylaxis orders into all heavily utilized order sets 7

8. Preventing DVT Implement DVT prophylaxis on patients at risk for DVT to include: Sequential compression devices (SCD’s) with or without anti thromboembolism stockings (TED’s) Anticoagulation and/or antithrombotic therapy as indicated Ambulation and/or activity as tolerated Exercise & stretch limbs (PT, OT, ROM) Adequate hydration 8

9. Recognize the Symptoms of DVT Pain and tenderness at the site Warmth of the skin around the site Swelling of the affected extremity Skin discoloration (blue and red) of the affected extremity Surface veins become more visible Left lower extremity with deep venous thrombosis (DVT) 9

10. Diagnosis of DVT Venous ultrasound or venous doppler often only diagnostic study Venogram may be indicated 10

11. Treatment of DVT DVT Treatments: Anticoagulant therapy Bed rest and elevation of the affected limb Fibrinolytic therapy is indicated in some DVT’s. 11

12. DVT to PE A DVT can become life- threatening if it breaks off and travels to the lungs becoming a pulmonary embolism also known as a PE. 12

13. Legs to Lungs and Heart 13

14. The Staggering Effects of PE It’s estimated that more than 600,000 patients each year will suffer a pulmonary embolism Pulmonary embolism either causes or contributes to up to 200,000 deaths each year in the United States One in every 100 patients who develop a DVT die due to pulmonary embolism A majority of pulmonary embolism are caused by DVT If PE is diagnosed & appropriate treatment initiated, the mortality rate can be reduced from approximately 30 percent to less than ten percent. 14

15. Signs and Symptoms of Pulmonary Embolism (PE) Sudden shortness of breath (most common) Chest pain (usually worse with breathing) A feeling of anxiety A feeling of dizziness, lightheadedness, or fainting Palpitations (heart racing) Coughing up blood (hemoptysis) Sweating Low blood pressure Symptoms of DVT 15

16. Diagnosis of PE Chest x-ray Ventilation-perfusion scan (V/Q scan) Pulmonary angiogram Spiral computed tomography (CT or CAT scan) Magnetic resonance imaging (MRI) Duplex ultrasound (US) Laboratory tests Electrocardiogram (ECG or EKG) Chest spiral CT scan w/contrast 16

17. Treatment of PE Treatment options include: Anticoagulants i.e. Heparin and Coumadin Fibrinolytic therapy Vena cava filter Percutaneous thrombectomy Pulmonary embolectomy 17

18. Prevention of PE To prevent a Pulmonary Embolism, there must be prevention of a Deep Venous Thrombosis from forming. 18

19. Long Term Effects of VTE Long term anticoagulation/DVT prophylaxis Recurrent DVT Post thrombotic syndrome 19

20. The Effects of VTE Deep Venous Thrombosis or DVT can cause:  Pain or tenderness in the affected extremity  Hospitalization or an extended length of stay if diagnosed during a hospitalization  Increased healthcare costs (medications, loss of work, possible long term complications and/or disabilities, etc.)  Possible death to the patient if the DVT breaks loose and travels to the lungs causing a pulmonary embolism or PE 20

21. Your Role In VTE Prevention Assess patient on admission Educate to prevent VTE Utilize VTE prophylaxis Continue to assess for VTE throughout hospital stay Discharge education 21

22. Surgical Patients and VTE 22

23. Making Your Work Count Process Measure Your compliance with: SCIP – VTE-1 SCIP – VTE-2 Numerator: # patients who met the SCIP VTE-1 & VTE-2 measures Denominator: # surgery patients >18 years-old 23

24. Making Your Work Count Outcomes Measure: PSI-12: Patients with post- operative PE/DVT Numerator: Discharges among cases meeting inclusion/exclusion rules for denominator with ICD- 9 codes for DVT or PE Denominator: All surgical discharges age 18 & older meeting specific DRG and ICD-9 codes 24

25. Resources Agency for Healthcare Research and Quality “Venous Thromboembolism (VTE) Prevention in the Hospital” @ http://www.ahrq.gov/qual/vtepresentation/maynardtxt.htmhttp://www.ahrq.gov/qual/vtepresentation/maynardtxt.htm “Cancer and Deep Vein Thrombosis: What You Should Know” @ http://www.clotcare.com/include/canceranddvt.pdf http://www.clotcare.com/include/canceranddvt.pdf HealthHype.com “Deep Venous Thrombosis (Leg Vein Clot), DVT Pictures, Symptoms @ http://www.healthhype.com/deep-venous-thrombosis-leg-vein-clot-dvt-pictures- symptoms.html http://www.healthhype.com/deep-venous-thrombosis-leg-vein-clot-dvt-pictures- symptoms.html HeartHealthyWomen.org “Deep Vein Thrombosis (DVT) @ http://www.hearthealthywomen.org/cardiovascular-disease/featured/deep-vein-thrombosis- dvt-pe.html http://www.hearthealthywomen.org/cardiovascular-disease/featured/deep-vein-thrombosis- dvt-pe.html Institute for Healthcare Improvement “Anticoagulation Management Toolkit” @ http://app.ihi.org/imap/tool/#Process=54aa289b-16fd-4a64-8329-3941dfc565d1 http://app.ihi.org/imap/tool/#Process=54aa289b-16fd-4a64-8329-3941dfc565d1 Institute for Healthcare Improvement “High-Alert Medication Safety Toolkit” @ http://app.ihi.org/imap/tool/#Process=b8541097-7456-4aab-a885-38c31950e6bf http://app.ihi.org/imap/tool/#Process=b8541097-7456-4aab-a885-38c31950e6bf Institute for Healthcare Improvement “Venous Thromboembolus (VTE) Prevention & Treatment Toolkit” @ http://app.ihi.org/imap/tool/#Process=5b9bfd5a-1e17-433b-a9d4- 602fafef73c8http://app.ihi.org/imap/tool/#Process=5b9bfd5a-1e17-433b-a9d4- 602fafef73c8 25

26. Resources Investigators Against ThromboEmbolism “Hormone replacement therapy and the risk of thrombosis” @ http://www.inate.org/en/1/2/6/958/default.aspxhttp://www.inate.org/en/1/2/6/958/default.aspx Johns Hopkins Medicine “Pulmonary Embolism” @ http://www.hopkinsmedicine.org/healthlibrary/conditions/respiratory_disorders/pulmonary_e mbolism_85,P01308/ http://www.hopkinsmedicine.org/healthlibrary/conditions/respiratory_disorders/pulmonary_e mbolism_85,P01308/ Mayo Clinic “Deep vein thrombosis (DVT)” @ http://www.mayoclinic.com/health/deep-vein- thrombosis/DS01005http://www.mayoclinic.com/health/deep-vein- thrombosis/DS01005 Medinfor.co.uk “Deep Vein Thrombosis (DVT) @ http://www.medinfo.co.uk/conditions/dvt.html http://www.medinfo.co.uk/conditions/dvt.html MedlinePlus “Thrombus” @ http://www.nlm.nih.gov/medlineplus/ency/imagepages/18120.htm http://www.nlm.nih.gov/medlineplus/ency/imagepages/18120.htm Medscape Today “Treatment of Symptomatic Lower Extremity Acute Deep Venous Thrombosis: Role of Mechanical Thrombectomy” @ http://www.medscape.com/viewarticle/567031 http://www.medscape.com/viewarticle/567031 Milford Vascular Institute “Deep Vein Thrombosis” @ http://milfordvascular.com/vascular- disease-mvi/deep-vein-thrombosishttp://milfordvascular.com/vascular- disease-mvi/deep-vein-thrombosis 26

27. Resources National Blood Clot Alliance Stop The Clot “Blood Clot Educations for Patients & Professionals” @ http://www.stoptheclot.org/http://www.stoptheclot.org/ NCBI “Venous Thromboembolism Safety Toolkit: A Systems Approach to Patient Safety” @ http://www.ncbi.nlm.nih.gov/books/NBK43659 http://www.ncbi.nlm.nih.gov/books/NBK43659 PreventDVT.org “What is deep-vein thrombosis?” @ http://www.preventdvt.org/default.aspxhttp://www.preventdvt.org/default.aspx RadiologyInfo.org “Venous Ultrasound (Extremities)” @ http://www.radiologyinfo.org/en/info.cfm?pg=venousus http://www.radiologyinfo.org/en/info.cfm?pg=venousus Sanofi “LOVENOX-proven for inpatient and outpatient treatment of acute DVT” @ http://www.lovenox.com/hcp/indications/dvt-treatment.aspx http://www.lovenox.com/hcp/indications/dvt-treatment.aspx Society of Interventional Radiology “Deep Vein Thrombosis Overview” @ http://www.sirweb.org/patients/deep-vein-thrombosis/ http://www.sirweb.org/patients/deep-vein-thrombosis/ WebMD “Deep Vein Thrombosis Health Center” @ http://www.webmd.com/dvt/default.htmhttp://www.webmd.com/dvt/default.htm Yale School of Medicine “Pulmonary Embolism” @ http://www.yalemedicalgroup.org/stw/Page.asp?PageID=STW030343 http://www.yalemedicalgroup.org/stw/Page.asp?PageID=STW030343 27