The Performance Gap
A venous thromboembolism (VTE) is defined as a blood clot in the lung (pulmonary embolism or PE) or in deep veins of the arm or leg (Deep Vein Thrombosis or DVT). VTEs are associated with increased mortality, poor patient outcomes, increased length of stay and decreased patient satisfaction. It is the most common preventable hospital complication as well as the most common cause of preventable mortality in hospitals. It is estimated that 60,000 to 100,000 Americans die from VTE each year and 10-30% of those patients will die within one month of diagnosis.\cite{20331949} VTE affects all races, ages and genders. It is estimated that over 50% of all VTE in a given community are associated with hospitalization.\cite{10737280} Healthcare institutions should take all precautions in order to prevent blood clots in their patients.
It is important to realize that even though trauma and surgery contribute to the risk for VTE, at least half of all hospital-acquired VTE occur in patients hospitalized with medical illnesses. Although classic clinical symptoms of DVT include red or painful swelling of a limb, the clinical examination for DVT is notoriously poor in both sensitivity and specificity. In some studies of hospitalized patients, only a minority of those found to have DVT have classical clinical findings to suggest the diagnosis.\cite{16003063} Because of this, clinical decision rules have been developed to help guide the diagnostic evaluation.\cite{Wells_1997} Although patients with acute PE typically endorse shortness of breath, tachypnea, and/or tachycardia, sudden cardiac arrest is the first symptom in 25% of PE patients.\cite{DHHSOIGVTE1} Thus one must maintain a high level of clinical suspicion to diagnose VTE. The better policy, both from a patient safety and a cost-consciousness point of view, is primary prevention to avoid their occurrence to begin with. All patients admitted to the acute care setting should be evaluated for their risk of VTE, and then guideline appropriate VTE prophylaxis should be reliably administered. This strategy results in significant reduction in the incidence of hospital-acquired VTE.
Once clinically suspected, clinical prediction rules should be utilized to guide appropriate diagnostic evaluation.(Cook 2005) Diagnostic imaging for confirmation includes venous doppler, V/Q scans or the highly sensitive computerized tomography angiography (CTA) of the chest. With the latter, small subsegmental, possibly non-clinical, pulmonary emboli can now be detected thus increasing a hospital’s reported VTE rate.
Patients who develop a VTE have a higher in-hospital mortality rate, and will have approximately 33% chance of developing another clot within 10 years.\cite{PresCouncilVTE1} Patients identified to have an acute VTE will require a secondary prophylaxis program. For most patients, this entails prolonged anticoagulation and close follow-up to carefully manage the risk and benefits of secondary prophylaxis.
Leadership Plan
Identify: Senior executive leadership that is committed to a reduction in VTE
- Team ideally is led by a physician and administrative champions, ideally the Chief Nursing Officer
- Gather staff that have an in-depth knowledge base of disease process and prevention of VTE such as:
- Physicians
- Nursing Leaders
- Advance Practice Providers such as Physical and Occupational Therapists
- Physicians in training
- Residents
- Bedside Nurses
- Quality Improvement staff
- Safety/Risk
- Pharmacy
- Information Technology team with Electronic Medical Record
Plan: Senior executive leadership and clinical /safety leaders should agree on the best implementations in order to close their performance gap.
- Plan should include measurable appropriate quality metrics
Timeline set: Senior executive leadership should select a goal and set a timeline to achieve said goal.
Resources allocated: Senior executive leaders should set specific budget for said goal and plan
System leadership and engagement: Clinical and safety leaders should act as change agents and drive implementation
Practice Plan
Complete in depth chart review of hospital-associated thrombosis events. Identify trends such as:
- Service line
- Physician
- Diagnosis
- Risk score (Appendix A: Caprini Score, Padua Prediction Score, IMPROVE score, or “3-bucket”model)
- Hospital units
- Pharmacological prophylaxis ordered
- Pharmacological prophylaxis missed doses
- Patient Refusal of pharmacological prophylaxis
- Mechanical prophylaxis ordered
- Patient refusal of mechanical prophylaxis
Identify gaps in care that promote VTE development
Adhere to the Agency for Healthcare Research and Quality’s Venous Thromboembolism Safety Toolkit: A System’s Approach to Patient Safety
Implement interventions that reduce VTE
- Ensure interventions are patient-centered
- Incorporate VTE Risk Assessment into EHR for all new admissions
- Reassess risk periodically upon change in level of care, clinicians, and prior to discharge.
- Ensure the ordering of appropriate VTE prophylaxis according to risk assessment and BMI
- Consider adoption of VTE power plans/order sets
- Continue VTE prophylaxis past discharge if recommended
- Ensure timely and reliable delivery of pharmacological and/or mechanical prophylaxis as indicated
- Track/trend missed doses, patient refusals and ensure that patient resistance or refusal is met with education about the purpose of prophylaxis and risks if not administered.
- Develop specific and reliable protocols, endorsed by local surgical champions, for reliable mechanical or pharmacologic prophylaxis to be applied prior to induction of anesthesia, as appropriate
- Consider nursing protocol for application of mechanical prophylaxis in pre-op areas
- Understand your staff’s perception of the importance of VTE prophylaxis
- Educate knowledge deficits
- Consider yearly competence in VTE
- Ensure that all team members - physicians, nurses, patient care assistants, trainees, pharmacists, transport personnel, physical therapists, patients and family members are aware of their role in VTE-P.
- Patient Mobility
- Utilize mobility trackers
- Design and implement a plan when pharmacological prophylaxis is contraindicated, such as proactive monitoring.
Educate patients and families about the risks, complications, the importance of VTE prophylaxis, and the symptoms of DVT and PE.
Technology Plan
Suggested technologies are limited to those proven to show benefit or are the only known technologies with a particular capability. Other technology options may exist or emerge after the publication of this APSS, please send information on any additional technologies, along with appropriate evidence, to info@patientsafetymovement.org. With regard to VTE, there are a few novel technology platforms that offer a low entry cost that work alongside the Electronic Health Record (EHR). These technology platforms are secure with multimedia functions and can host checklists, education and much more to improve best practices and engagement across the care continuum. There is also technology that is important in the prevention of blood clots, like compression devices. Examples of those devices and technology solutions are detailed below and may be helpful in VTE prevention.
Compression Devices
Either Graduated Compression Stockings (GCS) and/or Intermittent Pneumatic Compression Device (IPC), or AE (anti-embolic) pumps should be used adjunct to other forms of prevention, like pharmacological solutions
- Anti-embolism stockings, anti-thrombosis stockings, elastic support hose, graduated compression elastic stockings, Jobst stockings, surgical hose, TED hose, white hose, thrombosis stockings. When using GCS, appropriate fitting is essential to ensure safety from injury and effectiveness. Notably, 15-20% of patients cannot effectively wear AES because of unusual limb size or shape.\cite{Geerts_2001}
- Alternating Leg Pressure (ALP), athrombic pumps-calf/thigh, Continuous Enhanced Circulation Therapy (CECT), DVT boots-calf/thigh, EPC cuffs/ stockings-External pneumatic compression-calf/thigh, Flotron/Flotron DVT system-thigh, Impulse pump-thigh, Intermittent pneumatic compression stockings, Intermittent compression device (ICD), KCI stockings, Leg pumpers, PAS (Pulsatile anti-embolic stockings), Plexipulse-calf/thigh, Pneumatic intermittent impulse compression device, Rapid inflation asymmetrical compression (RIAC) devices, Sequential compression device, Sequential pneumatic hose, Thromboguard, Thrombus pumps-calf/thigh, Vascutherm, VasoPress DVT System, Venodyne boots-calf/thigh
Electronic Health Record (EHR)