DVT PROPHYLAXIS

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DVT PROPHYLAXIS

• Newport Hospital Initiative Update
• Mass Pro March 9th, 2006

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Newport Hospital Strategic Plan
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DVT Prophylaxis InitiativeDrivers

• Patient SafetyLEAP FROG-AHRQ
• Studies/Evidenced Based Guidelines (SCIP, ICU
  transformation VAP bundle)
• Strong opportunities for prevention
• Coordinating Team 1 Continuously Improve the
  quality of patient care and clinical outcomes

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DVT TeamNewport Hospital

• Formation 2002-Roll out OCT 04
• Review literature and best practices
• Explore issues/barriers
• Small Tests of change/PDCA
• Receive ongoing feedback from medical-nursing
  staff
• Assess protocol
• Ongoing PDCA process continues-06

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DVT Team Newport Hospital

• Opportunity statement
• An opportunity exists to improve the process
  of VTE prophylaxis beginning with identification
  and assessment of patients at risk for VTE and
  ending with implementation of preventive
  measures. This effort should improve patient
  safety and overall outcomes

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CQI Principles set structure
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Risk for DVT/VTE Geerts et al Chest 2001, 2004
Surgery/condition Risk of all DVT if untreated
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Top Risk Factors for DVT/VTE

• Increasing age
• Prolonged immobility
• Stroke
• Previous VTE
• Cancer
• Major Surgery (abdomen, pelvis and lower
  extremities)
• Indwelling central venous catheter
• Respiratory Failure
• Trauma (fx of pelvis, hip or leg)
• Obesity
• Varicose veins
• CHF and MI
• IBD
• Nephrotic Syndrome
• Oral contraceptives or postmenopausal repl
• Inherited predisposition
• Most of our patients had risk factors.

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Recommended DVT/VTE ProphylaxisHyers Am J Respir
Crit Care 1999Geerts et al Chest 2001, 2004
Bauer Blood 2002

• Risk group Recommended
  prophylaxis
• Hip replacement Warfarin, LMWH, fondaparinux
• Knee replacement Warfarin, LMWH, IPC,
  fondaparinux (Arixtra)
• Hip Fracture Warfarin, LMWH, fondaparinux
• Major trauma LMWH, IPC
• Abdominal surgery UFH, LMWH, IPC, warfarin, ES
• Medical Patients UFH, LMWH, ES
• IPC-Intermittent Pneumatic Compression
• (SCD - Sequential Compression Devices,
  Thromboguards)
• ES-Elastic stocking

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Prevention of Venous Thromboembolism Consensus
Recommendations

• NIH Consensus Development Conference (1986)
• Thromboembolic Risk Factors Consensus Group
• European Consensus Statement (1992)
• WHO Task Force on Pulmonary Embolism (1992)
• ACCP Consensus Conferences (1986, 1989, 1992,
  1995, 1998, 2001, 2004)
• DVT Coalition to Prevent DVT (2003)
• Consider JCAHO- new measures

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VTE Prophylaxis Assessment Form

• Assessment
• Contraindications
• Regimens for prophylaxis
• Selection for prophylaxis
• General considerations
• Recommended prophylaxis

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DVT/VTE Prophylaxis Order Set/ Education,Tools

• Order set development
• Patient education booklets,video/IPOC
• Present and approval by PT committee
• Presentation to all Medical Departments
• Present to Nursing Councils
• Pilot roll out (T5)-hospitalists April 04
• Rapid cycle revisions to process and orders
• Roll out to entire facility Oct 04
• Performance Monitoring and order set update
• 2005 - Ongoing feedback to physicians and nurses
  through PEI committees goal is quarterly made it
  x 2-3. Included in all JCAHO survey (Oct 05)
  prep, Magnet recertification
• 2006- Continue to monitor,keep performance in
  front of Physicians

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DVT Risk Assessment Responsibilities Physicians

• It is the responsibility of the admitting or
  treating physician to complete the DVT risk
  assessment form to fully assess and prevent VTE
  incidents
• 2005-We emphasize that the risk assessment form
  is there to help them provide documentation of
  rationale for treatment and prompts physician to
  place individuali9zed order in POM.
• 2006-Maintain ongoing performance feedback
  information with individualized data and
  departmental data in department meetings

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DVT Risk Assessment SetResponsibilities Nursing

• Ensure assessment form is in chart
• Prompt physician to complete the form
• Follow-up with physician if form not completed
  within 24 hours
• Provide patient with the DVT Prevention Teaching
  Guide and review with patient
• Document patient understanding of education on
  Education Record on IPOC

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DVT Risk Assessment SetResponsibilities Nursing

• Measure patient for elastic stockings as ordered
  with tape measure
• Check to ensure elastic stockings are properly in
  place every 4 hours
• Remove elastic stockings every 8 hours and check
  skin condition and immediately reapply
• Have patient perform ankle exercises every hour
  (12 repetitions)
• If SCDs are ordered do not remove for greater
  than ½ hour unless patient actively ambulating.
• 2006- Provide feedback quarterly to staff and
  departments

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Original Barriers on DVT Prevention

• Lack of awareness of DVT risk
• Perceived differences in risk assessment
• Perceived risks of bleeding with prophylaxis
• Inadequate prophylaxis

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Continued Challenges

• Orthopedic surgeons concerned with bleeding post
  op
• Hospitalist collaboration/
• communication with surgeons
• Paper vs technology
• Coagulation questions What to do after the
  hospital Ongoing monitoring responsibilities on
  providers
• Maintaining gain
• Sustaining focus

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Rapid Cycles

• Ongoing monitoring- ED has risk assessment forms
  available
• Placed risk assessment forms in progress notes
  section due to POM implementation
• SCDs originally delayed not enough held up roll
  out to hospital
• Refined audit tool to include nursing elements
• Risk assessment placed on line(web based) for
  reference POM order set developed
• Risk assessment documentation needed reiteration
  and rationale presentation by VPMA
• Administration promotes accountability
• Re-measure
• Goal gt 90 all pts assessed and as appropriate
  on DVT prophylaxis
• Discharge instructions clarified for home care
• Observe studies for Nursing home prophylaxis
  local Physicians want stronger evidence base
  studies for prescribing use. Opinions differ.

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What is driving us?

• Persistence
• Diligence
• Results
• Ongoing Literature reviews and discussion with
  medical staff
• Complications
• Patient Safety
• Board Expectation
• Public reporting
• Pride

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• References
• ACCP Guidelines 2004
• Websites
• IHI.org
• Preventdvt.org, dvt.net
• Venousinfo.com, chestnet.org
• JCAHO
• National Quality Forum (NQF)
• http//www.medqic.org/scip/scip_homepage.html
• http//www.clinicalconsensusreports.com/Secure/CLO
  T122004.pdf

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Newport Hospital DVT Team Members

• J Ehmann RN (PEI)
• B Grimes RPh
• Dr S Das (Neuro-surgeon)
• Dr D Jones(ortho)
• Dr H Derreza(Hospitalist)
• M Dunbar RN (ICU)
• Dr T McWilliams (VPMA)

• V Martin RN (M/S)
• J Kyle RN (ICU)
• L Dutra RN
• K Brothers (CM)
• D Garman RN (Nurse Ed)
• Ad hoc mbrs (OR, ED, RHB)