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Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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Page 1: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

Venous Thromboembolism (VTE) Prevention and

Anticoagulation Management -Part 1: Thromboembolism & National

Patient Safety Goal 3E Pharmacy Education

Page 2: 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

Page 3: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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

Page 4: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

$$$ Economic burden of VTE $$$

• 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

Page 5: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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

Page 6: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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

Page 7: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

Bed Rest!! … a DVT/ PE Red Flag!!!

BEDREST

Page 8: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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”

Page 9: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

DVT Prophylaxis: 3 Patient Groups

Low risk

Highest risk

Moderate/High risk

Page 10: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

• 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

Page 11: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

• 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

Page 12: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

• 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

Page 13: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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

Page 14: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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

Page 15: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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

Page 16: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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

Page 17: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

National Patient Safety Goal 3E:Anticoagulation

Page 18: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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

Page 19: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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)

Page 20: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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

Page 21: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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

Page 22: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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

Page 23: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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

Page 24: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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.

Page 25: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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)”

Page 26: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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

Page 27: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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.

Page 28: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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

Page 29: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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

Page 30: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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

Page 31: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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

Page 32: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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

Page 33: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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

Page 34: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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

Page 35: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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

Page 36: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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

Page 37: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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

Page 38: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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

Page 39: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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

Page 40: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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

Page 41: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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

Page 42: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy 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

Page 43: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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

Page 44: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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

Page 45: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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

Page 46: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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

Page 47: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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

Page 48: Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism & National Patient Safety Goal 3E Pharmacy Education

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