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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)
Venous Thromboembolism
Prophylaxis, June 2007, ICSI
– Current malignancy
– Estrogen therapy or
pregnancy
– History of MI, CHF,
COPD, or other
respiratory failure
– Stroke < 1 month
– Admission to the ICU
– Sepsis
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
Moderate/High risk
Highest risk
Low 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 23 times per day
– Sequential Compression Devices (SCDs) while in bed
Moderate/High 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
Very 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
Procedure related risk DVT/PE
Level of
Risk
Calf DVT
Proximal
DVT
Clinical
PE
Fatal PE
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%
Low
Increased risk up to 4-5 weeks postoperatively
ICSI: Venous Thromboembolism Prophylaxis
Fourth Edition/June 2007
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.
2.
3.
Cousins D et al. 2006
USP MedMarx data, 2005
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 & premixed 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
Hospital Acquired DVT per 1000 Discharges
12.00
10.00
8.00
Average
6.00
GOAL
4.00
2.00
0.00
J
N
W
Hospital Acquired PE per 1000 Discharges
3 .50
3 .0 0
2 .50
Average
2 .0 0
GOAL
1.50
1.0 0
0 .50
0 .0 0
J
N
W
Readmissions within 31 Days with
DVT per 1000 Discharges
M ont hl y A vg
1.20
GOA L
1.00
0.80
0.60
0.40
0.20
0.00
J
N
W
Readmissions within 31 Days with
PE per 1000 Discharges
1.40
M ont hl y A vg
1.20
GOA L
1.00
0.80
0.60
0.40
0.20
0.00
J
N
W
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.
b.
c.
d.
Hgb
INR and/or PTT
Cr
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- References
For more information, see the Joint Commission Website:
www.jointcommission.org
1.
2.
3.
4.
5.
6.
7.
Cousins D et al. 2006. Risk assessment of anticoagulation therapy.
National Patient Safety Agency. United Kingdom
USP MedMarx data, 2005
Fanikos J. et al. Medication errors associated with anticoagulant
therapy in the hospital. Am J Cardiol. 2004; 94: 532-5.
ICSI Venous Thromboembolism Prophylaxis Fourth Edition-June
2007
Chest 2005; 128; 958-969
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
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.
b.
c.
d.
e.
f.
g.
h.
Yearly nursing, pharmacy and provider education
Warfarin dosing for all patients will only be managed by
pharmacy
Defined hospital anticoagulation management program
Nutrition Services is notified of all patient’s receiving warfarin
all of the above
none of the above
a, c and d only
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.
b.
c.
d.
hypercoaguable state
endothelial injury
circulatory status
none of the above