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Preventing Venous Thromboembolism

Monday February 12, 2007
<B>Virginia Davis, RN, MSN, vice president of quality services at Methodist Health System in Dallas, and Gail Stover, RN, MBA, manager of surgical services (right), are pictured behind a patient undergoing treatment with a intermittent compression device, which is designed to stimulate blood flow.</B>
Virginia Davis, RN, MSN, vice president of quality services at Methodist Health System in Dallas, and Gail Stover, RN, MBA, manager of surgical services (right), are pictured behind a patient undergoing treatment with a intermittent compression device, which is designed to stimulate blood flow.
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It will come as no surpirse to nurses that hospitals are dangerous for ill and infirm patients due to the serious threat of venous thromboemoblism (VTE). Yet, most patients can avoid VTE with screening and prophylaxis.

On the cover: Methodist Dallas Medical Center nurses Tennesse Pitter, RN, (center) and Ray Burdios, RN, (right) assist a patient out of bed after a procedure.
Virginia Davis, RN, MSN, vice president for quality services at Methodist Health System in Dallas, agrees. "The more we know about the pathophysiology of [VTE] and what the evidence shows as good prevention, we can be stronger team members with the other professions and be great advocates for our patients."

VTE facts

VTE occurs when a blood clot forms in a blood vessel. The term is used to describe both deep vein thrombosis (DVT) and pulmonary embolism. DVT occurs when a clot develops in a deep vein, usually in the lower extremities or pelvis. A pulmonary embolism results when a clot or portion of a clot separates, travels to the lungs, and obstructs a pulmonary artery, a potentially life-threatening situation.

The American Academy of Family Physicians reports more than 200,000 people die every year from VTE-associated conditions.

Immobility is a key risk factor for developing a thrombus. "At greatest risk is anyone with a surgical procedure, especially on a lower extremity, anyone immobile, elderly or with a past history of a thrombotic event," says Lila Gunter, RN, MSN, a clinical nurse specialist at Grady Memorial Hospital in Atlanta.

"Fatal pulmonary embolism, where the clot obstructs a major vessel in the lung, is the most common but most preventable cause of in-hospital deaths," says Deborah Lambrinos, RN, MSN, director of clinical practice at Holy Cross Hospital in Fort Lauderdale, Fla.

Cancer, pregnancy, being overweight, having varicose veins, and taking birth control pills or hormone replacement therapy can increase the risk for VTE. A central venous catheter contributes to about 10% of cases, according to the National Heart, Lung and Blood Institute.

"VTE is often a silent killer," Lambrinos says. "The first sign might be cardiopulmonary arrest."

About half the patients with DVT experience signs or symptoms that include swelling, pain and tenderness, warmth, redness, or other discoloration of the skin. Symptoms of a pulmonary embolism may include chest pain upon deep inhalation and shortness of breath.

The National Quality Forum (NQF) estimated that more than 900,000 Americans suffer a DVT annually, and 500,000 of those develop a pulmonary embolism. Sixty percent of patients who develop pulmonary embolism die.

The Agency for Healthcare Research and Quality rates VTE the top patient safety problem with the greatest opportunity for change because of the low cost of implementing safety precautions.

"Screening patients and implementing measures to prevent venous thromboembolism (VTE) is very inexpensive and can save the organization a significant amount of money related to length of stay," adds Boreland. "The most important thing is patient safety. This initiative can improve patient outcomes and decrease mortality for an event that is easily preventable."

However, the NQF indicates that fewer than half the patients diagnosed and hospitalized with DVT received prophylaxis. The Joint Commission and the NQF began working two years ago developing national standards for the prevention and care of DVT; they released eight measures in 2006 for pilot testing in 33 randomly selected hospitals. For prevention, the team recommended that patients receive a VTE risk assessment and prophylaxis within 24 hours of hospital admission or with 24 hours of transfer to ICU.

Success at Methodist Health in Dallas

Methodist Health System in Dallas identified a need to improve its VTE rate in 2004. After evaluating prophylaxis regimens ordered by doctors, hospital administrators found that many physicians were not adhering to the latest recommendations.

As a result, the administrators convened a group of nurses, pharmacists, and physicians to develop a new order set with options for enoxaparin (Lovenox) at low-dose, unfractionated heparin, warafin, or intermittent pneumatic compression.

"We not only wanted to decrease our rate of VTE, but we also saw an opportunity on the medical staff side to help them understand better ways of prevention," Davis says.

Methodist Health System initially piloted the physician assessment form and order sets with orthopedic elective surgery patients; the form was expanded for use with all orthopaedic patients two weeks later.

As nurses became more competent assessing risk, they asked the hospital to modify a screen on the online medical record system to better capture at-risk patients. "Nursing saw they also had a role in identifying patients who might be at risk," Davis says. "They were strong patient advocates."

Methodist also addressed some nursing management and material management issues. The night shift earned the responsibility of placing the VTE order sheet on the chart. After nurses noted that there was a delay in starting patients on mechanical prophylaxis because they had to wait for the equipment to be delivered, the nurses recommended keeping the devices on the unit. As a result, material management staff arranged to keep sequential compression devices on all floors.

"This was a great initiative," Davis proudly proclaims. "We had nursing taking a key role in developing educational materials for the medical staff, nurses and other people involved."

During the first quarter of 2006, Methodist Health System experienced a 25% reduction in VTE events, compared to the first quarter of 2005. VTEs in surgical patients dramatically declined, Davis reports.

Georgia hospitals coming on board

Gwinnett Medical Center started its own VTE prevention program about a year ago and is moving toward standardized protocols. A multidisciplinary team developed order sets, a physician-initiated, quick risk assessment tool, and a scoring mechanism to determine patients at low, moderate or high risk of a VTE event.

When the hospital piloted the program, it found that many doctors were not initiating prophylaxis. Now, ED flow nurses complete the assessments.

"Once nursing became a direct part of this initiative we jumped to a reliable process," Boreland says. "We hit the 80th percentile [after] we started with 50 to 60% of patients receiving prophylaxis."

Gwinnett Medical Center also brought in outside speakers to educate physicians and nurses about the importance of VTE prevention.

Grady Memorial Hospital in Atlanta is developing a physician assessment tool and treatment regimen. The hospital has implemented an educational campaign and is focusing nurses' attention on assessing for signs of DVT every shift. Additionally, patients are instructed to exercise their lower extremities hourly.

"[Prevention is] one of the simplest, least costly and most important ways deep vein thrombisis can be prevented, and also early, as soon as possible, ambulation," Gunter says.

To encourage prevention, nurses administer pain medication before physical therapy sessions so patients are more comfortable. Nurses and technicians subsequently get patients up every shift and educate them about why moving is so important.

Henry Medical Center in Stockbridge, Ga., has focused its attention on staff education and pre-op teaching of patients scheduled for elective orthopaedic procedures, says Terri Weaver, RN, clinical coordinator for med-surg and orthopedics. This year, it plans to reach out and raise awareness of VTE in the community.

Florida prevention

Holy Cross Hospital began planning its VTE prevention program in 2003 and launched it in spring 2004. A chart review in 2003 found 188 cases of VTE. The hospital hoped implementing best-practices protocols would improve the VTE rate.

"It's very impressive," Lambrinos says. "We really reduced the number of VTE in both the surgical and medical populations."

Nurses screen every inpatient for VTE risk upon admission and enter their findings in the electronic health record on a page listing all the conditions associated with DVT and pulmonary embolism. Checking off two conditions automatically generates an order form, listing evidence-based prevention strategies.

"The more risk factors checked off, the more likely your patient will get VTE prophylaxis while in the hospital," Lambrinos explains. "If 10 things are checked off, it's appropriate to have a more aggressive prophylaxis regimen."

The medical staff collaborated with nursing in developing the protocols. Pharmaceutical prophylaxis options include: enoxaparin (Lovenox) 40 mg subcutaneously daily, enoxaparin (Lovenox) 30 mg subcutaneously daily for creatinine clearance of less than 30 ml/minute, or unfractioned heparin (UFH) 5000 international units subcutaneously every eight hours. If the physician opts to not prophylax, they must document the reason why on a checklist that includes everything from active bleeding to having undergone a spinal tap or epidural anesthesia within 12 hours.

The form also includes mechanical options, such as knee-high or thigh-high intermittent pneumatic compression, for use if medications are contraindicated or supplemental to the drug regimens.

"Pharmacological is the gold standard," Lambrinos says. "There are conflicting studies, but they say mechanical is not as effective. Actually, it is only as effective as compliance of the nurse or the patient."

Holy Cross Hospital has experienced dramatic results. In 2003, 13.2% of medical patients suffered a VTE. In the second quarter of 2006, the rate had fallen to 1.6%. For surgical patients, the rate decreased from 15.1% in 2003 to 3.1% in the second quarter of 2006. Prior to beginning the initiative, 53% of patients received prophylaxis, now more than 80% do.

"Before, we would find patients that fell through the cracks," says Linda Cassidy, RN, EdM, CCRN-CSC, a critical care clinical specialist at Holy Cross. "Now, we're finding that patients are consistently getting the prophylaxis they need. It has made such a big difference."

If physicians do not respond to the order sheet, nurses follow up and remind them about needed prophylaxis orders. Critical care unit champions also review compliance.

"It's a learning curve, but they are pretty much on board," Cassidy says. "We've raised the consciousness enough."

Lambrinos and Cassidy consider the program's simplicity and education as key to their success. To coincide with the initiative's start, Holy Cross brought in a national speaker for physician and nurse educational breakfast and lunch programs. The hospital simultaneously held community lectures and contacted the media about the program, generating news reports about VTE and the importance of prevention, and about the need for patients to discuss DVT with their physician.

"We have within our power the ability to prophylax or prevent VTE," Lambrinos says. "There are simple prophylactic steps every hospital can take to impact the number of deaths in hospitals."

Debra Anscombe Wood, RN, is a freelance writer. To comment, e-mail cjohnson@gannetthg.com.