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National Patient
Safety Goal 3E:
AnticoagulationNursing Education
Objectives
• List requirements for meeting standards for the
National Patient Safety Goal 3E- Anticoagulation
• Identify risk factors for VTE development in
hospitalized patients
• List 3 symptoms of DVT/PE development
• List the 3 patient risk groups for VTE development
and 2 appropriate interventions for each risk group
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
National Patient Safety Goals
• Goals and Requirements are developed by
experts from various fields
• Approved by the Joint Commission's Board
in June 2007
• New Goals may be added each year or goals
may be continued for more than one year (ex.
Med-Rec)
National Patient Safety Goal 3E:
Anticoagulation
• Reduce the likelihood of patient harm with
the use of anticoagulation (AC) therapy
• Rationale: Anticoagulation therapy is a
high risk treatment (due to complexity with
dosing, patient compliance with treatment,
& monitoring)
Risks with Anticoagulant Therapy
• Anticoagulation medications are listed as one of the
top 5 drug classes for patient safety incidents¹
• Reported meds involved in harmful events² include :
Heparin, Warfarin, Enoxaparin
• Heparin errors are usually attributed to the non-use of
programmable infusion pumps and non-standardized
IV concentration of Heparin drips³
1.
2.
3.
Cousins D et al. 2006
USP MedMarx data, 2005
Fanikos J. et al. 2004
National Patient Safety Goal 3E:
Nuts & Bolts
• 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
National Patient Safety Goal 3E:
Nuts & Bolts
•
Requirement for 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 AC therapy
National Patient Safety Goal 3E:
Nuts & Bolts
•
Requirement for 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
(MedNet safety pump- in drug library)
–
Policy addresses baseline & ongoing lab tests for
Heparin/LMWH
National Patient Safety Goal 3E:
Nuts & Bolts
•
Requirement for 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)”
Venous Thromboembolism (VTE):
Prevention and
Anticoagulation Management
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
Post-Test Questions
$$$ Economic burden of VTE $$$
• 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
Risk Factors for VTE development
– Decreased mobility
– Current malignancy
– Age (especially >75)
– Estrogen therapy or
pregnancy
– Personal history of
DVT/PE or clotting
disorder
– Surgery- LE joint
replacement open
abdominal, urologic, or
gynecologic procedure
– Inflammatory conditions
Venous Thromboembolism
Prophylaxis, June 2007, ICSI
– History of MI, CHF,
COPD, or other
respiratory failure
– Stroke < 1 month
– Admission to the ICU
– Sepsis
Causes for VTE development
• Venous stasis- immobility
• Vein injury- surgery, IV
therapy, phlebotomy
• Increased coagulation-
cancer, inflammatory conditions
or infectious process
Virchow’s Triad
Bed Rest!! … a DVT/ PE Red
Flag!!!
BEDREST
Signs and symptoms of DVT or PE
• Pain, cramps or heaviness in affected extremity
• Parathesias- 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 bedrest
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
– SCD’s 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
SCD’s while in bed
Enoxaparin 40mg subQ every day start 12-24 hrs. after surgery
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 hx. of DVT, PE or clotting disorder
• Recommendations:
– Early ambulation- this means up walking in hallway 2-3 times per
day
– SCD’s while in bed
– Enoxaparin 40mg subQ every day start 12-24 hrs. after surgery
– If orthopedic patient- follow orthopedic anticoagulation protocol
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– Providers to risk stratify patients into risk
categories based on current diagnosis and previous
medical history (VTE Order Set PO 1190)
• Early ambulation
• Medication 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)
• Patient with bacterial endocarditis
• Patient with active hepatitis or hepatic insufficiency
Venous Thromboembolism
Prophylaxis, June 2007, ICSI
New HCD DVT/PE Assessment
screens
• New DVT/PE assessment screens have been built in
HCD- will replace “Homan’s assessment” under
muskuloskeletal body system
• This assessment is under the “FLOWSHEET” tab in
HCD
• The DVT/PE assessment will be completed with all
nursing assessments
New HCD DVT/PE Assessment
screens
• The DVT/PE assessment includes:
– Calf assessment for pain, redness, warmth,
tenderness or swelling
– Respiratory signs & symptoms of SOB or
difficulty breathing
– Includes area for documentation of “MD
NOTIFICATION” if patient has any of the
above present
New HCD DVT/PE Assessment Screens
New HCD DVT/PE Assessment screens
New HCD DVT/PE Assessment screens
New HCD DVT/PE Education screens
• New DVT/PE Education screens have been built in HCD
(requirement to meet NPSG 3E standards)
• Documentation is under the “EDUCATION” tab in HCD
• The DVT/PE education will be completed and documented at
least once during the hospitalization (requirement to meet
NPSG 3E standards)
• Discharge RN must verify that DVT/PE education has
been documented on the patient
• Enoxaparin and Coumadin Patient Education Written materials
have been updated and will no longer require for nursing to
document on these
New HCD DVT/PE Education
screens
• For Bethesda only- Nursing will continue to document on
the brown border education flowsheet
• The DVT/PE education includes:
– Patient education on diagnosis of DVT/PE or preventative
information
– Documentation of consult to Dietician for additional drug/food
interaction education (checking this tab will not automatically
place order for consult- the consult must be manually entered)
– Patient/family education on Sx. of PE/DVT, medications,
medication purpose, food/drug interactions, drug monitoring, and
Lovenox demo
– Written or video education on coumadin and/or Lovenox
New HCD DVT/PE Education screens
New HCD DVT/PE Education screens
New HCD DVT/PE Education screens
New HCD DVT/PE Education screens
New HCD DVT/PE Education screens
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.
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
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
anticoagulation 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
Future steps……
• Development of a VTE Dashboard with all system
measures for each site
• Creation of a VTE Collaborative Practice
Committee with participation by all site leads
• Continue assessing progress with VTE work at
each site
• Yearly nursing, pharmacy and provider education
(requirement for NPSG 3E)
NPSG 3E: Anticoagulation- References
For more information, see the Joint Commission Website:
www.jointcommission.org
1.
2.
3.
4.
5.
6.
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 Chartbook of 2000-2004 Findings from Intensive Care Units and Radiological
Services. Rockville, MD: USP Center for the Advancement of Patient
Safety; 2005
Post-Test Questions
1. Which of the following are requirements for
meeting the NPSG 3E standards?
a. Yearly nursing, pharmacy and provider education
b. Warfarin dosing for all patients will only be managed
by pharmacy
c. Defined hospital anticoagulation management
program
d. Dietary notification of all patient’s receiving warfarin
e. Answers A, C, D
2. Which are risk factors for VTE development?
a. decreased 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
3. Which are symptoms of DVT/PE development?
a. SOB and anxiety
b. Chest heaviness (without cardiac explanation)
and bruising of extremity
c. Tenderness/pain upon palpation of calf and
SOB
d. Redness/edema of extremity and high INR
4. What are the risk factors for the “Very High”
Patient 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
5. What must be documented on discharge for
DVT/PE patient education?
a. diagnosis or preventative information, sx. Of
DVT/PE, medications, and food/drug
interactions
b. diagnosis or preventative education, activity,
diet, and food/drug interactions
c. Home monitoring, food/drug interactions and
follow-up appointments
d. Food/drug interactions, outpatient therapy, and
medications