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Venous Thromboembolism (VTE) Prevention and
Anticoagulation Management -Part 1: Thromboembolism & National
Patient Safety Goal 3E Pharmacy Education
Objectives• Identify four risk factors for VTE development in
hospitalized patients• List three symptoms of DVT/PE development• List the three patient risk groups for VTE
development and two appropriate interventions for each risk group
• List five requirements for meeting standards for the National Patient Safety Goal 3E - Anticoagulation
The Problem…..
• 2 million Americans will be afflicted with deep vein thrombosis (DVT) each year
• As many as 600,000 will subsequently develop a pulmonary embolism (PE)
• In about 300,000 people the PE may prove to be fatal
• Third most common cause of hospital-related deaths in the U.S.
The most common preventable cause of hospital death
$$$ Economic burden of VTE $$$
• Cost of care related to VTE (cases of DVT and PE together) in the U.S. each year is estimated at 1.5 billion
• Post-op thromboembolic complications add an average of $18,300 to the total hospital costs for each patient in which they happen
Causes for VTE development• Venous stasis- immobilization,
age>40, obesity, CHF, MI, general anesthesia, varicose veins
• Vein injury- trauma, surgery, CV catheter, history of thromboembolism (TE), cardiac pacemaker
• Increased coagulation- malignancy, high dose estrogen, pregnancy, polycythemia vera, activated protein C resistance, AT III deficiency, hyperhomocysteinemia, antiphospholipid syndrome, nephrotic syndrome
Virchow’s Triad
Risk Factors for VTE development– Decreased mobility – Increased age (especially
>75)– Personal history of
DVT/PE or clotting disorder
– Surgery- LE joint replacement open abdominal, urologic, or gynecologic procedure
– Inflammatory conditions– Obesity (BMI≥30)
– Current malignancy
– Estrogen therapy or pregnancy
– History of MI, CHF, COPD, or other respiratory failure
– Stroke < 1 month
– Admission to the ICU
– Sepsis
Venous Thromboembolism Prophylaxis, June 2007, ICSI
Bed Rest!! … a DVT/ PE Red Flag!!!
BEDREST
Signs and symptoms of DVT or PE
• Pain, cramps or heaviness in affected extremity
• Paresthesias- unexplained numbness or tingling
• Redness and edema of affected extremity
• Tenderness and pain in calf upon palpation
• Shortness of breath
• Chest heaviness (without cardiac explanation)
• Sense of “impending doom”
DVT Prophylaxis: 3 Patient Groups
Low risk
Highest risk
Moderate/High risk
• Patient Group:– Age <60– Minor surgical procedure– Medical patient on bed rest– Pregnant patient or patient on oral contraceptives or
hormone replacement
• Recommendations for prophylaxis:– Early ambulation- this means up walking in hallway 2-
3 times per day– Sequential Compression Devices (SCDs) while in bed
Low risk
• Patient Group:– Age >60– Central venous access– History of previous malignancy– History of medical risk factors CHF, COPD, inflammatory bowel
disease– Medical patient with additional risk factors (CHF, COPD, Sepsis, MI)– Major surgery planned with additional risk factors
• Recommendations:– Early ambulation- this means up walking in hallway 2-3 times per day– SCDs while in bed– Pharmacologic prophylaxis indicated - start 12-24 hrs. after surgery
once hemostasis has occurred– If orthopedic patient- follow orthopedic anticoagulation protocol
Moderate/High risk
• Patient Group:– Age >75– Elective hip or knee surgery– Active cancer– Hip, pelvis or leg fracture (<1 month)– Stroke (<1 month)– Admission to ICU– Personal history of DVT, PE or clotting disorder
• Recommendations:– Early ambulation- this means up walking in hallway 2-3 times per
day– SCDs while in bed– Pharmacologic prophylaxis indicated - start 12-24 hrs. after
surgery once hemostasis has occurred– If orthopedic patient- follow orthopedic anticoagulation protocol
Very High Risk
Procedure related risk DVT/PELevel of Risk
Calf DVT Proximal DVT
Clinical PE
Fatal PE
Low 2% 0.4% 0.2% 0.002%
Moderate 10%-20% 2%-4% 1%-2% 0.1%-0.4%
High 20%-40% 4%-8% 2%-4% 0.4%-1%
Very High 40%-80% 10%-20% 4%-10% 0.2%-0.5%
ICSI: Venous Thromboembolism ProphylaxisFourth Edition/June 2007
Increased risk up to 4-5 weeks postoperatively
Medical Condition Risk DVT
Condition Risk of DVT
General Medical 10%-26%
MI 17%-34%
Stroke 11%-75%
CHF 20%-40%
Medical ICU 35%-42%
Chest 2005; 128;958-969
Prevention techniques
• Risk assessment tools- – Risk stratify patients into risk categories based
on current diagnosis and previous medical history
• Early ambulation
• Pharmacologic prophylaxis if indicated based on patient’s VTE risk level
Venous Thromboembolism Prophylaxis, June 2007, ICSI
Contraindications to drug therapy
• Active, significant bleeding
• Extreme thrombocytopenia (<50,000)
• History of heparin induced thrombocytopenia (HIT)
• Uncontrolled hypertension (SBP >200, DBP >120)
• Other conditions that could increase risk of bleeding
Venous Thromboembolism Prophylaxis, June 2007, ICSI
National Patient Safety Goal 3E:Anticoagulation
Purpose of the Joint Commission’s National Patient Safety Goals
(NPSG’s):• Published by the Joint Commission annually• Purpose of National Patient Safety Goals (NPSG):
– Promote specific improvements in patient safety
– Highlight problem areas in health care
– Describe evidence-based solutions
– Focus on system-wide solutions
Purpose of National Patient Safety Goal 3E: Anticoagulation
• Reduce the likelihood of patient harm with the use of anticoagulation (AC) therapy
• Goal applies to multiple inpatient and outpatient settings (ambulatory care, hospitals, home care, long-term care, etc.)
• Rationale: Anticoagulation therapy is a high risk treatment (due to complexity with dosing, patient compliance with treatment, & monitoring)
National Patient Safety Goal 3E
• Goal applies to the use of heparin, low molecular weight heparins, warfarin and other anticoagulants
• One year phase-in period for all hospitals with full implementation by January 1, 2009
Risks with Anticoagulant Therapy
• AC’s are listed as one of the top 5 drug classes with patient safety incidents¹
• Reported meds involved in harmful events²:
#3 Heparin, #5 Warfarin, #11 Enoxaparin
• Heparin errors typically involve infusion pump and IV delivery errors³
1. Cousins D et al. 20062. USP MedMarx data, 20053. Fanikos J. et al. 2004
National Patient Safety Goal 3E • Requires that all JCAHO accredited institutions:
– Implement a defined anticoagulation program
– Use ONLY oral Unit Dose products & pre-mixed IV’s
– Warfarin is dispensed for each individual patient with established monitoring
– Use approved protocols for the initiation & maintenance of anticoagulation therapy
National Patient Safety Goal 3E
• Requires that all JCAHO accredited institutions:
– With the use of Warfarin – baseline/current INR is available for all patients for therapy adjustment
– Dietary services is notified of all pt’s receiving warfarin- food/drug interaction education
– Heparin IV is delivered by a programmable IV pump
– Policy addresses baseline & ongoing lab tests for Heparin/LMWH
National Patient Safety Goal 3E
• Requires that all JCAHO accredited institutions:
– Provide education on anticoagulation therapy for all providers, staff, patients, and families
– Pt./family education covers specific areas: follow-up, dietary restrictions, monitoring, complications, and food & drug interactions
– Evaluation of Anticoagulation safety practices.
National Patient Safety Goal 3E: Surveying and Scoring
• Joint Commission will evaluate actual performance with standards of the “Goal”
• All requirements must be implemented
• Facility will be found either “Compliant or Not Compliant”
• Failure to comply will result in a “Requirement for Improvement (RFI)”
HealthEast’s work on VTE Prevention
& Anticoagulant Management
• Measures (How will we know that a change is an improvement?)
– Hospital Acquired DVT per 1000 Discharges
– Hospital Acquired PE per 1000 Discharges
– Readmissions within 31 Days with DVT per 1000 Discharges
– Readmissions within 31 Days with PE per 1000 Discharges
– Patient harm associated with anticoagulant therapy as measured by the IHI Adverse Drug Event Trigger Tool
HealthEast’s work on VTE Prevention
& Anticoagulant Management
• Aims (What are we trying to accomplish?)
– Reduce the incidence of DVT and PE in hospitalized patients by 50% in one year.
– Reduce readmissions within 31 days for DVT and PE by 50% in one year.
– Reduce patient harm associated with the use of anticoagulant therapy by 50% in one year.
DVT Prevention• Clinical Goals:
– Adult patients (18 & older) are assessed for VTE (DVT & PE) risk within 24 hours of admission
– Appropriate pharmacological and/or mechanical prophylaxis begins within 24 hrs of admission
– All patients receive education regarding VTE signs & symptoms, preventive methods
– All patients begin early and frequent ambulation
Venous Thromboembolism Prophylaxis, June 2007, ICSI
DVT Prevention
• Clinical Goals:
– All adult medical/surgical patients with moderate-high or very high VTE risk receive pharmacologic prophylaxis unless contraindicated
– Reduce the risk of complications from pharmacologic prophylaxis.
Venous Thromboembolism Prophylaxis, June 2007, ICSI
DVT Prevention
• Clinical Goals:
– Appropriate pharmacological and/or mechanical prophylaxis begins within 24 hrs of admission
– Mechanical prophylaxis is used when pharmacologic prophylaxis is contraindicated
– Appropriate precautions for patients receiving spinal or epidural anesthesia are implemented
Venous Thromboembolism Prophylaxis, June 2007, ICSI
HealthEast Current Baseline Data
• Hospital Acquired DVT per 1000 Discharges
• Hospital Acquired PE per 1000 Discharges
• Readmissions with DVT per 1000 Discharges
• Readmissions with PE per 1000 Discharges
Data collected during FY ‘07
0.00
2.00
4.00
6.00
8.00
10.00
12.00
J N W
Average
GOAL
Hospital Acquired DVT per 1000 Discharges
Hospital Acquired PE per 1000 Discharges
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
J N W
Average
GOAL
0.00
0.20
0.40
0.60
0.80
1.00
1.20
J N W
Monthly Avg
GOAL
Readmissions within 31 Days with DVT per 1000 Discharges
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
J N W
Monthly Avg
GOAL
Readmissions within 31 Days with PE per 1000 Discharges
HE Anticoagulation Safety Practices • Standardized therapeutic Heparin premixed IV
concentration, with infusion rate chart labels• Smart Pump for Heparin infusion• Restricted access to multiple strengths of Heparin
– Heparin Flush 100 units/ml-only strength available for flush use in adults on override
• Standardized weight based order sets (Heparin, LMWH’s) with standard labs – for orders outside of protocol, direct prescriber to use
the order set or obtain separate labs orders
HE Anticoagulation Safety Practices
• Heparin boluses and LMWH doses dispensed by pharmacy as exact doses
• Do not use abbreviation for “U” on handwritten or typed orders
• Saline flush used for peripheral catheters– Only central lines (PICC/Port-a-cath) & dialysis
catheters require Heparin flush• Bar code technology & CPOE (coming to all
sites)• Heparin-Induced Thrombocytopenia (HIT)
Standard orders
HE Anticoagulation Safety Practices• Warfarin administration at standard time of 1700
– Allows review of laboratory results (INR, etc)
• Guidelines available for standard and rapid reversal of warfarin
• Warfarin dispensed in exact patient doses (U/D)• Warfarin teach packets and RN patient education• New HED documentation available for RN
documentation of education • RN independent double checks of therapeutic IV
Heparin doses
HE Anticoagulation Safety Practices• Pharmacists role
– For any weight based therapeutic orders for use of Heparin or LMWH, verify the order, obtain an accurate weight in kilograms and transcribe the appropriate dose (if needed). Review baseline labs.
– Pay attention to drug interactions/duplication of therapy warnings in HMM (e.g. To prevent LMWH and Heparin duplications, significant interactions, etc)
– Enter INR monitoring into HMM for warfarin
HE Anticoagulation Safety Practices• Pharmacists Role:
If therapeutic Heparin or LMWH hand written orders received:
1. request use of order set
2. Or, obtain separate lab orders as required by the protocol
a. Hgb
b. INR and/or PTT
c. Cr
d. Platelets
Future steps…..
• Development of a VTE Dashboard with all system measures for each site
• Creation of a VTE Collaborative Practice Committee with participation by representatives from all sites
• Continue assessing progress with VTE work at each site
• Annual nursing, pharmacy and provider education
NPSG 3E: Anticoagulation- ReferencesFor more information, see the Joint Commission Website:
www.jointcommission.org
1. Cousins D et al. 2006. Risk assessment of anticoagulation therapy. National Patient Safety Agency. United Kingdom
2. USP MedMarx data, 20053. Fanikos J. et al. Medication errors associated with anticoagulant
therapy in the hospital. Am J Cardiol. 2004; 94: 532-5.4. ICSI Venous Thromboembolism Prophylaxis Fourth Edition-June
20075. Chest 2005; 128; 958-9696. Santell JP, Hicks RW, Cousins DD. MEDMARX Data Report: A
Chart-book of 2000-2004 Findings from Intensive Care Units and Radiological Services. Rockville, MD: USP Center for the Advancement of Patient Safety; 2005
7. ISMP Medication Safety Alert; Volume 12, issue 1; Recommended Safety Improvements for Anticoagulants. January 11, 2007
Post-Test Questions
1. Which of the following are requirements for meeting the NPSG 3E standards?
a. Yearly nursing, pharmacy and provider educationb. Warfarin dosing for all patients will only be managed by
pharmacyc. Defined hospital anticoagulation management programd. Nutrition Services is notified of all patient’s receiving warfarine. all of the abovef. none of the aboveg. a, c and d onlyh. b, c and d only
Post-Test Questions
2. Which are risk factors for VTE development?
a. increase mobility, obesity, and sepsis
b. decreased mobility, joint, surgery and history of DVT/PE
c. decreased mobility, age <40, and history of CHF
d. cancer, age >40, and pregnancy
Post-Test Questions
3. Which grouping has the correct symptoms of DVT/PE development?
a. oxygen use and anxiety
b. chest heaviness (without cardiac explanation) and bruising of extremity
c. tenderness/pain upon palpation of calf and shortness of breath
d. redness/edema of extremity and high INR lab value
Post-Test Questions
4. What are the risk factors for the “Very High” risk group?
a. age >60, active cancer, and history of CHF
b. age >60, central venous access, and major abdominal surgery
c. age >75, bedrest and minor surgical procedure
d. age >75, active cancer and admission to ICU
Post-Test Questions
5. What is the pharmacist’s role in safety with anticoagulation use?
a. Verify weight and dose on any therapeutic Heparin or low molecular weight heparin order.
b. Review any drug interaction or duplication of therapy notices in HMM for anticoagulants and intervene appropriately if needed.
c. Request use of standard order sets and standard labs when hand written orders received for heparin or low molecular weight heparin.
d. Dispense exact dose of Heparin boluses and low molecular weight heparin doses.
e. All of the above
Post-Test Questions
6. Which of the following is NOT part of Virchow’s triad in the development of pathogenic thrombus?a. hypercoaguable state
b. endothelial injury
c. circulatory status
d. none of the above
