Text of DVT Prophylaxis and Pulmonary Embolism Karen Ruffin RN, MSN Ed
Slide 1
DVT Prophylaxis and Pulmonary Embolism Karen Ruffin RN, MSN
Ed.
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Frequency in the US Up to 2 million people are affected
annually by Venous Thromboembolism(VTE). Of those 2 million people
it is estimated that 300,000 of them will develop and die from a
Pulmonary Embolism (PE). The highest incidence of PE is with
hospitalized patients. Autopsy shows that as many as 60% of
patients dying in the hospital have had a PE, but the diagnosis is
being missed 70% of the time. According to: Center for Disease
Control (CDC), Department of Health and Human Services, Food and
Drug Administration (FDA), The Surgeon General
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Percentage if at risk for Development of a VTE All hospitalized
patients, depending on acuity, have between a 10%-48% of developing
a VTE All hospitalized patients, depending on acuity, have between
a 10%-48% of developing a VTE Med-Surg patients placed on bed rest
for a week (10%-13%). Med-Surg patients placed on bed rest for a
week (10%-13%). Patients in the MICU (29%-33%). Patients in the
MICU (29%-33%). Patients with Pulmonary Disease on bed rest for 3
or more days (20%-26%). Patients with Pulmonary Disease on bed rest
for 3 or more days (20%-26%). Patients in the CCU with an MI
(27%-33%). Patients in the CCU with an MI (27%-33%). Patients who
are asymptomatic after a CABG (48%). Patients who are asymptomatic
after a CABG (48%). Feied, C.F. & Handler, J.A., (2008)
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Mortality and Morbidity Approximately 10% of the patients with
an acute PE will die with in the first 60 minutes. Approximately
10% of the patients with an acute PE will die with in the first 60
minutes. 1/3 of those who live, the condition is diagnosed and
treated. 1/3 of those who live, the condition is diagnosed and
treated. 2/3 of the remaining patients go undiagnosed. 2/3 of the
remaining patients go undiagnosed. Deaths that are a result of
VTE/PE were shown to be the most common cause of preventable
hospital deaths THAT IS HUGE! According to: Center for Disease
Control (CDC), Department of Health and Human Services Food and
Drug Administration (FDA), The Surgeon General
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Mortality and Morbidity Race- Subtle population differences may
exist, but the incidence is high in all racial groups. Race- Subtle
population differences may exist, but the incidence is high in all
racial groups. Sex- Women only when they are pregnant. Sex- Women
only when they are pregnant. Age- Although the frequency for
developing a PE increases with age, age alone is not an independent
risk factor. It has more to do with co-morbidities. Age- Although
the frequency for developing a PE increases with age, age alone is
not an independent risk factor. It has more to do with
co-morbidities.
Vessel Damage Endothelial cells allow blood to flow with ease
through vessels. Factor VIII or Willibrands Factor
Conditions/lifestyles that damage vessel walls: Past VTE- Pressure
Ulcers Smoking- Cellulites High Cholesterol Varicose Veins
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Vascular Constriction Trauma Surgery Insertion of central line
Varicose Veins Restricted Mobility Sepsis Induction MI HF Stroke
Any external force that cause damage to the vascular system can
cause slow blood flow
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Blood Viscosity Dehydrating Birth Control Pills High estrogen
states Pregnancy Postpartum Cancer Sepsis Blood transfusions
Obesity IBS Hematologic Disorders Elevated Blood Sugar Platelet
Aggregation
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Physiology of Clotting
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What is the difference between a thrombus and an emboli? A
thrombus is a clot that is stationary and a emboli is a thrombus
that has broken off and is traveling. A thrombus is a clot that is
stationary and a emboli is a thrombus that has broken off and is
traveling.
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Most Common Cause of a PE 90% are thrombi dislodged from deep
veins in the calf. 90% are thrombi dislodged from deep veins in the
calf. Some originate in the pelvis, particularly in pregnant women.
Some originate in the pelvis, particularly in pregnant women. Fat
embolus occur when long bones are broken (this is rare). Fat
embolus occur when long bones are broken (this is rare).
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What is a Pulmonary Embolism (PE)? Occlusion of a portion of
the pulmonary vascular bed by an embolism. They can be a: Occlusion
of a portion of the pulmonary vascular bed by an embolism. They can
be a: Thrombus (Blood Clot) Tissue Fragment Lipids (Fat) Air
Bubble
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Pathophysiology Once the embolus is released into the blood
stream they are distributed in: Once the embolus is released into
the blood stream they are distributed in: 65% of the time both
lungs 65% of the time both lungs 25% of the time right lung 25% of
the time right lung 10% of the time left lung Lower lobes are 4
times more often upper lobes.
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Pathophysiology Massive Occlusion- an embolus that occludes a
major portion of the pulmonary circulation. Massive Occlusion- an
embolus that occludes a major portion of the pulmonary circulation.
Embolus with Infarction- An embolus that is large enough to cause
an infarction (death) of a portion of lung tissue Embolus with
Infarction- An embolus that is large enough to cause an infarction
(death) of a portion of lung tissue Embolus without Infarction- Not
sever enough to cause permanent lung injury. Embolus without
Infarction- Not sever enough to cause permanent lung injury.
Multiple Pulmonary Emboli- This can be chronic or recurrent.
Multiple Pulmonary Emboli- This can be chronic or recurrent.
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Risk Factors for DVT and PE Previous episode of thromboembolism
Previous episode of thromboembolism Prolonged immobility Prolonged
immobility Cancer Cancer Obesity Obesity Pregnancy Pregnancy Oral
estrogen Oral estrogen Fever Fever Atrial fibrillation Atrial
fibrillation CHF, Shock CHF, Shock Varicose veins Varicose veins
Over 60 y/o Over 60 y/o Hematologic disorders Hematologic disorders
Trauma Trauma Central Lines Central Lines Dehydration Dehydration
Hypovolemia Hypovolemia Surgical Patients Surgical Patients
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Prophylaxis Strategies The evidence based practice guidelines
published by the ACCP in June 2008 incorporated data obtained from
a comprehensive literature review of the most recent studies
available. The recommendations are broken up in to different
categories from general patient populations to specific groups and
conditions. American College of Chest Physicians, (2008)
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Understanding the Different Recommendation Categories Grade 1:
Benefits outweigh risk Grade 2: Less certain about the magnitude of
benefits versus risk Grade A: High quality evidence Grade B:
Moderate quality evidence Grade C: Low quality evidence American
College of Chest Physicians, (2008)
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General Patient Population Every hospital should have a formal
strategy for addressing VTE prophylaxis (Grade 1A) Mechanical
methods of thromboprophylaxis should be used primarily in patients
who have a high risk of bleeding (Grade 1A) It is recommended
against the use of aspirin alone as thromboprophylaxis for VTE for
any group of patients (Grade 1A) American College of Chest
Physicians, (2008)
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What about patients w/ a PICC line?????? We are a seeing and
increased incidence of DVT in patients with PICC lines. We are a
seeing and increased incidence of DVT in patients with PICC lines.
How can we assess for it? How can we assess for it?
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Clinical Manifestation of PE Massive Occlusion- Profound shock,
hypotension, tachycardia, pulmonary hypertension, and chest pain.
Massive Occlusion- Profound shock, hypotension, tachycardia,
pulmonary hypertension, and chest pain. Embolus with Infarction-
Pleural pain, pleural friction rub, pleural effusion, hemoptysis,
fever, and leukocytosis. Embolus with Infarction- Pleural pain,
pleural friction rub, pleural effusion, hemoptysis, fever, and
leukocytosis. Recurrent PE- Occur in individuals who have had a
history of previous emboli. Recurrent PE- Occur in individuals who
have had a history of previous emboli.
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Applying the Nursing Process Assessment Assessment Diagnosis
Diagnosis Planning Planning Intervention Intervention Evaluation
Evaluation
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Assessment and Symptoms Homons sign Homons sign H&P H&P
Cough Cough Sudden onset of SOB Sudden onset of SOB Agitation
Agitation Lightheadness Lightheadness Fainting Fainting Dizziness
Dizziness Sweating Sweating Anxiety Anxiety Rapid Breathing Rapid
Breathing Tachycardia Tachycardia Air Hunger Air Hunger
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What are your nursing diagnosis going to be??? Tell me your
long and short term goals.
Cost of Prevention vs. Treatment???? V/Q scan- $1500 V/Q scan-
$1500 ICU bed $9000 day ICU bed $9000 day Arterial Angiogram- $3200
Arterial Angiogram- $3200 Many other realted cost????? Many other
realted cost????? Sequential stockings- $10 day Sequential
stockings- $10 day Heparin subq- pennies a day Heparin subq-
pennies a day Lovenox subq $15 a day Lovenox subq $15 a day
Assessment and Documentation We must assess if a patient is at
risk for the development of a VTE Document that assessment
Communicate with the health care team that the patient is at risk
for a VTE. Document that communication Education, Education,
Education
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Why are all those steps important???? The Joint Commission and
the Centers for Medicare and Medicaid have implemented VTE quality
measures for surgical patients which include the Surgical Care
Improvement Project (SCIP 1 & SCIP 2). SCIP 1 evaluates if
patients were identified as being at risk, was prophylaxis ordered
appropriately. SCIP 2 examines if prophylaxis was actually received
by patient. Surgical types include: ortho, gyn, urological,
elective spine, intracraneal. Appropriate prophylaxis includes:
LDUFH, Fundaparinux, LMWH, warfarin
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Why are all those steps important???? The CMS has created
guidelines on payment for service for healthcare providers that use
evidence based practice to promote the best possible outcomes for
its customers.
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In 2005, section 5001(c) of the Deficit Reduction Act of 2005
(DRA) authorized the Secretary of the Department of Health and
Human Services to select conditions that: (1) are high cost, high
volume, or both; (2) are identified through ICD-9-CM coding as
complicating conditions (CCs) or major complicating conditions
(MCCs) that, when present as secondary diagnoses on claims, result
in a higher-paying MS-DRG; and (3) are reasonably preventable
through the application of evidence-based guidelines.
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So what does that mean to the bedside nurse? We must encourage
all healthcare members to follow best practices as outline by
creditable bodies such as the ACCP. Our role in assisting with
reimbursement for care provided is to appropriately assess our
patients and determine who is at risk for VTE/PE. Next we must
communicate this information with the physicians. Once orders are
receive for thromboprophylaxis we should ensure that treatment is
delivered as soon as possible or within 2 to 3 hours of receiving
the orders.
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The Power of Suggestion!! Dont ever underestimate
it!!!!!!!
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Case Studies 37y/o women presented to the ER 18 days s/p
laparotomy for lyses of adhesions. 37y/o women presented to the ER
18 days s/p laparotomy for lyses of adhesions. Symptoms- CP, SOB,
lightheadness, tachycardia. Symptoms- CP, SOB, lightheadness,
tachycardia. She was seen by an NP and not by an MD. CBC, Cardiac
Enzymes, and Chem 7 ordered and were normal. Pt was sent home and
told to follow up with her primary in two days. She was seen by an
NP and not by an MD. CBC, Cardiac Enzymes, and Chem 7 ordered and
were normal. Pt was sent home and told to follow up with her
primary in two days. Pt. suffered a nonfatal PE that night. She was
awarded $1,000,000.00 Pt. suffered a nonfatal PE that night. She
was awarded $1,000,000.00
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Case Study Nurse was to D/C a pt. home. She noted a large
reddened, raised, warm area on the pt. right ankle. The nurse
documented it, but did not notify the physician. Nurse was to D/C a
pt. home. She noted a large reddened, raised, warm area on the pt.
right ankle. The nurse documented it, but did not notify the
physician. The pt. suffered a fatal PE two days later. A claim was
filed against the nurse and was settled for $4,000,000.00. The pt.
suffered a fatal PE two days later. A claim was filed against the
nurse and was settled for $4,000,000.00.
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Case Study Pt. was admitted with a fractured right hip on Sat
morning. Patient was started on Lovenox 30mg subq daily. That order
was renew on Monday after the patient had an ORIF of the right hip.
The order was missed for 2 days. The patient suffered a non-fatal
PE was transferred to the ICU. The hospital stay was extended by 3
weeks. A claim was filed against several nurses and was settled for
$1,500,000.00 and medical expenses. Pt. was admitted with a
fractured right hip on Sat morning. Patient was started on Lovenox
30mg subq daily. That order was renew on Monday after the patient
had an ORIF of the right hip. The order was missed for 2 days. The
patient suffered a non-fatal PE was transferred to the ICU. The
hospital stay was extended by 3 weeks. A claim was filed against
several nurses and was settled for $1,500,000.00 and medical
expenses.
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-American College of Chest Physicians, (2008). Antithrombotic
and Thrombolytic Therapy: American College Of Chest Physicians
Evidence Based Clinical Practice Guidelines. 8th Edition. Volume
133/number 6 (Suppl) pages 67s-968s. -Center for Disease Control,
(2008). Are you at risk for deep vein thrombosis? Retrieved from
http://www.cdc.gov/Features/Thrombosis on December 12, 2008.
-Center for Medicare and Medicaid Services, (2008). CMS improves
patient safety for Medicare and Medicaid by addressing never
events., CMS Manual System. -Feied, C.F. & Handler, J.A.,
(2008). Pulmonary Embolism. Retrieved from eMedicine.com on
December 12, 2008. -Galson, S.K., (2008) The Surgeon General calls
to action to prevent deep vein thrombosis. US Department of Health
and Human Services Office of the Surgeon General. Retrieved from
http://www.surgeongeneral.gov on December 12, 2008. -National
Institute for Health, (2007). What is a Deep Vein Thrombosis?
Retrieved from http://www.nhlbi.nih.gov/health/dci/Diseases/Dvt on
December 12, 2008. -Sanofi-Aventis, (2008). The Coalition to
Prevent Deep-Vein Thrombosis. Retrieve from,
http://www.preventdvt.org on December 12, 2008. -Sumpio, B.E.,
Riley, J.T, Dardik, A. (2002). Cells in focus: endothelial cell.
Department of Surgery, Yale University School of Medicine. Retrieve
from http://www.ncbi.nlm.nih.gov on December 12,
2008.http://www.cdc.gov/Features/Thrombosishttp://www.surgeongeneral.govhttp://www.nhlbi.nih.gov/health/dci/Diseases/Dvt
on December 12http://www.preventdvt.org
http://www.ncbi.nlm.nih.gov
