Cyrena De RamosSt. Cloud State UniversityNovember 12, 2014

• Understand data supporting the significance of VTE prophylaxis for medical patients

• Recognize 3 core measures related to VTE prophylaxis

• Understand correct use and contraindications for pharmaceutical VTE prophylaxis

• Understand correct use, fit, and contraindications for mechanical VTE prophylaxis

• Identify various ways to improve patient compliance/use of VTE prophylaxis

• VTE comprising pulmonary embolism(PE) and deep vein thrombosis (DVT), accounts for 5% -10% of all deaths among hospitalized patients

• DVTs affect as many as 600,000 patients annually• PEs are recognized as the most common cause of

preventable hospital deaths and account for up to 200,000 deaths annually.

• 10% to 20% of medical patients acquire DVTs• Only 40% of at-risk medical patients receive

guideline recommended VTE prophylaxis

• 60% of DVTs and 50% of PEs could be avoided with proper use of VTE prophylaxis

• 100,000 lives could be saved annually with proper use of VTE prophylaxis

• 360,000 individuals would avoid the negative consequences of DVTs

VTE-1 Venous Thromboembolism Prophylaxis

VTE-2 Intensive Care Unit Venous Thromboembolism Prophylaxis

VTE-3 Venous Thromboembolism Patients with Anticoagulation Overlap Therapy

VTE-4 Venous Thromboembolism Patients Receiving Unfractionated Heparin with Dosages/Platelet Count Monitoring by Protocol or Nomogram

VTE-5 Venous Thromboembolism Warfarin Therapy Discharge Instructions

VTE-6 Hospital Acquired Potentially-Preventable Venous Thromboembolism

Measure 1 – VTE Prophylaxis Administer Pharmaceutical Prophylaxis in a timely manner

Apply and document Mechanical Prophylaxis by midnight on hospital day 2

• Documentation must state “on” or “refused”

Measure 5 – VTE Warfarin Therapy Discharge InstructionsWarfarin (Coumadin) teaching provided and documented prior

to discharge• Documentation must reflect “literature” was provided

Measure 6 – Hospital Acquired potentially-preventable VTE

Med 1 has had 1 instance of Hospital Acquired VTE

• Pharmacologic prophylaxis should include heparin or a related product– LMWH such as Enoxaparin (Lovenox)– Warfarin (Coumadin)

• Preferred method of VTE prophylaxis when not contraindicated

• Pharmacologic prophylaxis is more effective than mechanical prophylaxis

• Implemented unless the risk for bleeding outweighs the expected benefit

• Continue throughout course of hospitalization, including at discharge

• Warfarin (Coumadin) Up to 10 mg/dose, adjusted based on INR

Approximately 5 days to reach therapeutic levels

Taken Orally Administered daily for 3-12 months or

indefinitely

• Active Bleeding• High-risk uncontrolled hemorrhage • Bleeding disorders, Thrombocytopenia, and/or

Conditions in which bleeding would be catastrophic• Renal dysfunction• Liver disease with Coagulopathy• Hypersensitivity to Heparin or LMWH• INR > 1.5• Spinal Tap or Epidural Anesthesia• Intracranial and/or Intraocular Surgery within 6 weeks• Major Trauma/Closed Head Injury/Intracranial Bleed• Uncontrolled Hypertension (SBP>200 mmHg, DBP> 110

mmHg)

• Mechanical VTE prophylaxis includes: – Thromboembolism-Deterrent Hose (TEDs)/ACE Wraps– Intermittent Pneumatic Compression Devices (IPCDs)– Foot Impulse Devices (FIDs)

• For patients unable to receive pharmacological VTE prophylaxis, or in conjunction with pharmacologic VTE prophylaxis

• Use as IPCDs and FIDs as much of the time as is possible and practical, both when in bed and when sitting in a chair

• TEDs should be worn day and night until the patient no longer has significantly reduced mobility (TEDs generally last about 3 months)

• Continue to use mechanical VTE throughout the hospital stay, frequent ambulation is not a substitute

• Ensure patients have their legs measured and the correct size is provided• Re-measure legs in patients who develop edema or postoperative swelling• Remove TEDs twice daily for 30 minutes for hygiene and to skin inspection

• IPCD DevicesKnee Length

Calf circumference

Thigh Length

Upper thighcircumference at buttock fold

Do not use TEDs on patients who have: Peripheral arterial bypass grafting Peripheral neuropathy or other causes of sensory impairment Any local conditions in which stockings may cause damage, for example

fragile 'tissue paper' skin, dermatitis, gangrene or recent skin graft Cardiac failure Severe leg edema or pulmonary edema from congestive heart failure Unusual leg size or shape Major limb deformity preventing correct fit.

• Use caution and clinical judgment when applying TEDs over venous ulcers or wounds.

• If arterial disease is suspected, seek expert opinion before TEDs• Stop using TEDS if there is marking, blistering, or discoloration of the

skin, or if the patient experiences pain or discomfort; may request order for FIDs or IPCDs

Do not use IPCDS on patients who have:

Any local leg condition in which the sleeves may interfere, such as: dermatitis, vein ligation [immediate postoperative] gangrene, recent skin graft.

Severe arteriosclerosis or other ischemic vascular disease. Massive edema of the legs or pulmonary edema from congestive heart

failure Extreme deformity of the leg Suspected pre-existing deep venous thrombosis

Do not use FIDs on patients who have: Conditions where an increase of fluid to the heart may be detrimental Congestive Heart Failure Pre-existing deep vein thrombosis, thrombophlebitis or pulmonary

embolism

Provide clear and comprehensive patient education on VTE, health risks, and benefits to VTEo Include literature for the patient to reviewo Explain the patient’s individual risk factors

Investigate the reason for refusalo Brainstorm ideas with the patient to overcome barriers and implement

prophylaxis

Provide a consistent messageo All members of the healthcare team must provide the patient with similar

reliable information regarding the importance of VTE prophylaxis, including consistent use of prophylaxis

Be a patient advocateo If a patient refuses one method of VTE prophylaxis, ask the physician if they

would like to order an alternative method (Ex. Patient refuses Heparin but is willing to use IPCD)

Be persistent!o Continue to reinforce the education and ask the patient on a regular basis if

they would like to begin using VTE prophylaxis

Lorraine is a 68-year-old woman with a past medical history of coronary artery disease (CAD) (s/p MI x 2, coronary artery bypass graft [CABG 8 years ago), hyperlipidemia, hypertension, and heart failure. She is admitted with a 1-week history of fatigue, shortness of breath at rest, and a 15-pound weight gain over the last week. She is diagnosed with acute decompensatedheart failure and diuretic therapy is initiated.

Mimi is a 73-year-old woman admitted to the medical unit with pneumonia. She has been hospitalized frequently over the last 2 months for a brain tumor, which was removed 5 weeks ago. She has been very weak since the surgery and can only pivot transfer.

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