PATIENT SAFETY FIRST Prevention of Venous Thromboembolism SHARON A. McNAMARA, MS, BSN, RN, CNOR
D
eep vein thrombosis (DVT) is defined as a blood clot that occurs in a deep vein in the body, often in the leg or thigh1; a pulmonary embolism (PE), however, occurs when a clot breaks free and enters the arteries of the lungs.2 Both DVT and PE are forms of venous thromboembolism (VTE), and both are important health concerns.3,4 The Agency for Healthcare Research and Quality (AHRQ) reports VTE as the most common preventable cause of hospital deaths.5 The prevention of DVT and PE should be a priority for the entire health care profession. Patients who undergo surgical and other invasive procedures face increased risks that make it imperative that the perioperative RN understand DVT and PE prophylaxis, and can take an active role in DVT prevention. CAUSATIVE FACTORS AND RISK Two million patients experience some form of VTE annually, either during a hospital stay or within 30 days after discharge, and most hospitalized patients have at least one risk factor for VTE.5 Twentythree million surgeries are performed annually in the United States, and 20% of surgical patients are in a high-risk category (eg, patients undergoing hip and knee arthroplasty, patients with a hip fracture) to develop proximal DVTs, thus intensifying the importance of prevention.5 Proximal DVT is the most dangerous because it frequently leads to PE if the patient does not receive anticoagulant
prophylaxis.5 One in 10 surgical patients develops a DVT and dies; this represents more deaths than those from breast cancer, AIDS, and traffic accidents combined.5 The AHRQ estimates the costs in treatment and increased length of stay for DVT to be $10,000 and for PE to be $20,000 per patient.5 In the current financial environment and culture of patient safety, prevention is an important concept when discussing VTEs. A patient may present with a primary causative factor for DVT (eg, venous stasis, vessel-wall injury, hypercoagulability), but it is important to remember that DVT risk is elevated for all surgical patients, including children. This is because routine surgical situations, such as immobility, tissue trauma, and surgical positioning requirements, place all surgical patients at risk for DVT.6,7 Venous thromboembolism risk and coagulation status vary within the population, and coagulation status may change for an individual patient several times throughout his or her hospital experience, related to medication changes, weight, age, renal function, invasive interventions, and previous VTE prevention options.8 The Virchow triad refers to the group of risk factors that are necessary for VTE to occur: venous stasis, vessel-wall injury, and hypercoagulability. Each condition alone raises risk, but, when combined, risk escalates. Patients at high risk for venous stasis have conditions that include the elements of the Virchow triad. Examples of high-risk patients include those who
The AORN Journal is seeking contributors for the Patient Safety First column. Interested authors can contact Sharon A. McNamara, column coordinator, by sending topic ideas to [email protected]. http://dx.doi.org/10.1016/j.aorn.2014.02.001
642 j AORN Journal
May 2014
Vol 99
No 5
Ó AORN, Inc, 2014
PATIENT SAFETY FIRST n n n n n n n
n
are older than 40 years of age, have had cancer or are being treated for the cancer, have cardiac disease (eg, congestive heart failure, myocardial infarction), have been on prolonged bed rest or immobilized, have had surgery longer than 30 minutes, have varicose veins, have experienced prolonged periods of travel (eg, more than four to 10 hours in the previous eight weeks), or are pregnant or postpartum.5-10
Evaluating patients for vessel-wall injury risk includes identifying those who currently have certain risk factors or those with a history of certain risk factors, which include n n n n n n
VTE or stroke, surgery, trauma, extensive burns, cancer and its associated therapy, and the presence of a central venous catheter.5-10
Hypercoagulability risks include patients with a history of certain factors. These include n n n n n
cancer and its associated therapy, recent trauma, recent pregnancy or postpartum period, oral contraceptive use or hormone replacement therapy, and inherited or acquired thrombophilia.5-10
In addition to the above risk factors, patients who have acute medical illnesses, infectious processes, or inflammatory conditions, including inflammatory bowel disease, active rheumatic disease, sickle cell disease, or acute and chronic lung disease; are smokers; or are dehydrated also may have an increased risk for DVT. Patients with any of these risk factors exhibit a greater potential for DVT.5-10 Frequently, it is the nurse who assesses the patient, identifies the patient’s risks, categorizes the risks, and implements a DVT prevention protocol
www.aornjournal.org
or contacts the physician for an order for prophylaxis. AORN’s “Recommended practice for prevention of deep vein thrombosis”8 provides a guide for the perioperative RN to provide care for the patient and to participate in the development of a framework or protocol for VTE prevention. The recommended practices document plus a literature review, including the information from AHRQ and the American College of Chest Physicians, provide support protocols that apply to all patients but which can be individualized after the nurse performs a DVT assessment on the patient on admission and regularly throughout the patient’s hospital stay. The AORN practice recommendations help the perioperative nurse select appropriate prophylaxis by linking the patient’s VTE risk to a corresponding menu of proven options. When caring for patients with elevated risk, multidisciplinary teamwork and communication during transitions of care become very important. Hand overs among the preoperative, intraoperative, and postoperative nurses should include information about the individual patient’s primary causative factors for VTE and the surgery’s implications or effects on the patient’s risk factors. Hand-over communication also should address any interventions, either pharmacologic or mechanical, that are in place or may need to be implemented. Multidisciplinary Teamwork Convening a multidisciplinary team to develop and implement an organization-wide DVT prevention protocol should be the first step in organizing VTE prevention protocols. It is crucial that nurses be a part of any team that develops these policies, procedures, and protocols. In addition, the group should include surgeons, internists with critical care experience, anesthesia professionals, pharmacists, and hematologists. Additional participants will depend on the organization and its resources but may involve, for example, representatives from patient safety or rehabilitation areas. The protocol created by this team should be supported by evidence-based models that are risk based and AORN Journal j 643
May 2014
PATIENT SAFETY FIRST
Vol 99 No 5
that consider both mechanical and pharmacologic treatment, contraindications, and possible complications. Surgical committees and specialty societies have identified best practices, areas of controversy, and contraindications that should be considered when developing a VTE prevention protocol.5,7,9-12 After developing the protocol, health care providers should have easy access to the protocol as well as all supporting evidence. To be effective, the protocol must provide a process that is simple to apply to all patients within the organization’s scope of service. Performing a thorough patient assessment on admission and at the time of any change in clinical condition provides information necessary to determine the patient’s risk for VTE and assists health care providers in identifying the appropriate mechanical or pharmacologic prophylaxis measures needed. Identifying an individual patient’s risk factors and contraindications for mechanical or pharmacologic treatment allows practitioners to evaluate and categorize the patient’s level of risk as low, moderate, or high, and, based on the risk assessment, the physician or advanced practice nurse can then prescribe treatment. Many examples of interventions are available in the literature, but it is important for practitioners at each facility to customize interventions to the patient population served when developing a VTE protocol and order set, and for health care professionals to individualize interventions to each patient.5,9-11 To improve patient assessment and intervention reliability in the process, health care professionals should use a risk-assessment screening tool that helps them link the patient’s risk to a menu of treatment choices and a standard written order set that connects the risk assessment to a prophylaxis choice.12 As important as identifying when risk assessments must be performed, determining who will perform the assessments is key. Nurses frequently assume this role, but physicians and pharmacists complete risk assessments in some organizations through VTE trigger tools (ie, screening assessment questions that trigger further investigation). 644 j AORN Journal
Monitoring is necessary to determine whether assessments are being performed reliably and, if not, to make changes to the assessments and the personnel who perform them.12 Mechanical DVT Prophylaxis The perioperative RN should implement specific interventions when the patient is ordered to receive mechanical DVT prophylaxis. Mechanical interventions are used throughout the perioperative period. n
Preoperatively, measures may include n use of graduated compression stockings or n intermittent pneumatic compression devices (IPCD). n Intraoperatively, measures may include n inspection and maintenance of any preoperatively applied mechanical DVT prophylaxis; n assessment of preoperatively applied IPCD for correct size; n careful positioning; and n repositioning, if possible, during procedures that last more than four hours. n In the immediate postoperative period, measures may include n early ambulation; n active and passive foot and ankle exercises, which create natural muscle compression of the legs’ venous system; and 8 n reducing venous stasis. Graduated compression stockings and IPCDs reduce venous stasis and improve venous return from the legs. Graduated compression stockings perform this function by constant compression of the calves, and IPCDs perform this function by sequentially and intermittently compressing a sleeve that encompasses the patient’s feet, calves, or entire legs to mimic the natural action of the leg muscles. They are available in foot, knee, and thigh sleeves that may be inflated as a single unit or sequentially. Nurses should apply IPCDs according to manufacturer’s written instructions for use and should properly fit the IPCDs to the
PATIENT SAFETY FIRST individual patient. The VTE protocol should specify when the nurse should disconnect the IPCDs from the pumps and when to perform skin assessment. There are contraindications and possible complications in the use of mechanical DVT prophylaxis. It is important that the nurse consider these when performing the patient’s risk assessment and when making treatment decisions. Contraindications include n
n
n n n
conditions that affect the lower extremities (eg, arteriosclerosis, peripheral vascular disease, neuropathy, dermatitis, cellulitis, infections, injuries, surgical sites); conditions that compromise lower extremity blood flow (eg, severe arteriosclerosis, ischemic vascular disease, massive leg edema); sensitivity to latex, if wraps and tubing are not latex free; severe congestive heart failure; and thigh circumference that exceeds the limit of the instructions for use.5,8
Possible complications from the use of mechanical DVT prophylaxis could include
www.aornjournal.org
assessment of the patient and surgical procedure. The RN must verify that the order for pharmacologic treatment is unambiguous and accurate before administration of the medication. The seven rights of medication practices should be observed (ie, right patient, right medication, right dose, right time, right route, right indication, right documentation).8 Attention to the correct concentration of these medications is an important safety concern. It also is important that the RN knows the weight of the patient and any known allergies. Assessing contraindications for the use of prophylactic pharmacologic intervention in the individual patient is key for the RN to identify to help ensure positive outcomes. Use of pharmacologic methods for VTE prophylaxis has proven to be safe and effective if individualized to the patient, and is cost effective.10,11,13 Nursing knowledge of contraindications and complications for pharmacologic VTE prophylaxis is important to patient safety. Contraindications to the use of pharmacologic prophylaxis include n n n
n
n
n
n
compartment syndrome, latex sensitivity or allergy, n peroneal nerve injury or palsy, and 5,8 n skin injury.
n n
Pharmacologic DVT Prophylaxis Pharmacologic prophylaxis (ie, the use of medications to alter coagulation) is very complex and is a medical responsibility. The physician must make the decision to use pharmacologic prophylaxis based on the patient’s risk factors, anticipated surgery, and contraindications, and he or she should not rely on standardized orders or protocols but should use a framework that guides the development of an individualized plan for each patient.5,7,9-11 The pharmacologic framework may include various medication options (enoxaparin, heparin, unfractionated heparin, warfarin, fondaparinux) and dosages, choices are based on the risk
complex trauma; recent hemorrhage; infective endocarditis; ocular, neurologic, or other recent surgery; pregnancy; recent intracranial, gastric, or genitourinary bleeding; and recent (ie, within 24 hours) lumbar or neuraxial anesthesia.5,8
Complications of pharmacologic prophylaxis may include n n n n n n n n
bleeding, compartment syndrome, hematoma formation, heparin-induced thrombocytopenia, osteoporosis or osteopenia, skin necrosis, thrombocytopenia, and urticaria at the injection site.5,8
Pharmacists are key decision support personnel for VTE protocols, especially when patients have
AORN Journal j 645
May 2014
PATIENT SAFETY FIRST
Vol 99 No 5
contraindications to pharmacologic treatments, and they are important members of the multidisciplinary team for planning, implementation, and day-to-day clinical care. The pharmacist is a valuable resource to physicians and nurses, and is important to the success of the VTE prevention program and the pharmacologic safety of the patient.
n
NURSING IMPLICATIONS Nurses often become key practitioners in implementing new or updated practices. It is important to communicate upcoming changes and educate care providers about the changes to facilitate frontline staff members having what they need to successfully implement change. This aspect of the VTE prevention initiative may involve educators providing the initial VTE education and prevention protocol competency evaluations. Educators can use stories of previous patients who experienced a VTE and required additional treatment or readmission to help motivate personnel and make the assessment process real.12 Educating the patient and his or her family members, and engaging them in VTE prevention and the treatment plan are important nursing interventions. This information helps the patient and his or her family members understand and identify potential complications (eg, leg pain, swelling, unexplained shortness of breath, wheezing, chest pain, palpitations, anxiety, sweating, coughing up blood), the importance of compliance, and the correct usage of mechanical and pharmacologic prophylaxis measures as well as the necessary information to report to the physician. Incorporating “teach back” methods into the education process to determine whether the patient understands the material being taught is an additional skill that nurses can use.9 Patient and family member education about VTE prevention should include
n
n
current and future risk factors; n the importance of staying hydrated; n signs and symptoms of VTE;
646 j AORN Journal
n n n
reasons to avoid constrictive clothing, sitting with legs crossed or knees bent, or sitting or standing for long periods; reasons to elevate the legs when sitting; explanations of passive and active exercises for the lower extremities; directions on how to perform frequent coughing and deep-breathing exercises if the patient is confined to bed; and an explanation of the physiology of blood flow and clot formation.8,9
Documentation of nursing interventions and education should include the patient assessment, care plan, nursing diagnosis, desired outcomes and interventions, and evaluations of the patient’s response to care.7 The development of a VTE protocol, order set, and risk-assessment tool should help the nurse provide comprehensive documentation. Collaboration with information technology personnel can facilitate acquiring documentation tools and inclusion of hard stops (ie, when mandatory information is required, the computer program does not allow the user to continue until the information is provided) for ordering in the electronic medical record. Information technology personnel also may be able to design programs or filters to identify patients who are at risk for VTE via fields already submitted to the patient’s electronic medical record and to automatically flag patients at various risk levels.9 IMPLEMENTATION The development team should create a quality improvement plan for sustaining the protocol that describes how compliance to the protocol will be tracked, by whom, and to whom compliance will be reported. This should take place before implementing any changes so that the reporting structure and level of accountability are built into the system. The communication plan for quality improvement processes should include staff members and physicians as well as individuals who are high enough in the organization to elicit accountability from all
PATIENT SAFETY FIRST levels. Implementation should include hospitalspecific VTE data to highlight the need for improving VTE prevention. The protocol team should create an investigation process that includes a defect analysis on all VTEs so that team members can learn the common causes of VTEs as well as identify any special cause variations that occur. In addition to collaborating on the prevention protocols, nurses also may be responsible for developing an equipment purchase and distribution plan for sequential compression power packs and stockings to minimize treatment delays.9 To do this effectively, an understanding of VTE prevention and the available products is needed. CONCLUSION The participation of the nurse in VTE initiatives and prevention is imperative. Perioperative nurses have an ethical obligation to “participate in establishing, maintaining, and improving health care environments and to the provision of quality health care consistent with the values of the profession through individual and collective action.”14(p36) The perioperative nurse plays an important role as an autonomous patient advocate whose ability to assess the patient and his or her environment, implement and evaluate treatment, assess the potential implications involved in complex patient positioning, and ensure accurate hand overs between patient care areas by communicating clinical information that will assist in the prevention of VTE. The nurse’s critical thinking skills and knowledge will facilitate leading efforts to prevent VTE to protect the patient and create a culture of safety. References 1. What is deep vein thrombosis? National Heart, Lung and Blood Institute. http://www.nhlbi.nih.gov/health/health -topics/topics/dvt/. Accessed January 13, 2014. 2. What is a pulmonary embolism? National Heart, Lung and Blood Institute. http://www.nhlbi.nih.gov/health/ health-topics/topics/pe/. Accessed January 13, 2014. 3. Centers for Disease Control and Prevention. Venous thromboembolism in adult hospitalized patients e United States, 2007-2009. MMWR Morb Mortal Wkly Rep. 2012; 61(22):401-404. http://www.cdc.gov/mmwr/preview/ mmwrhtml/mm6122a1.htm. Accessed January 16, 2014.
www.aornjournal.org
4. Beckman GE, Hopper C, Critchley SE, Ortel TL. Venous thromboembolism: a public health concern. Am J Prev Med. 2010;38(4 Suppl):S495-S499. 5. Preventing hospital acquired venous thromboembolism: a guide for effective quality improvement. Agency for Healthcare Research and Quality. http://www.ahrq.gov/ professionals/quality-patient-safety/patient-safety-resources/ resources/vtguide/index.html. Accessed January 14, 2014. 6. Ahonen J. Day surgery and thromboembolic complications: time for structured assessment and prophylaxis. Curr Opin Anaesthesiol. 2007;20(6):535-539. 7. Rawat A, Huynh TT, Peden EK, Kougias P, Lin PH. Primary prophylaxis of venous thromboembolism in surgical patients. Vasc Endovasc Surg. 2008;42(3):205-216. 8. Recommended practices for prevention of deep vein thrombosis. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014: 421-430. 9. Failure mode and effects analysis venous thromboembolism prophylaxis. Partnership for Patient Care. ECRI Institute Healthcare Improvement Foundation. 2007. https://www.ecri.org/Documents/Patient_Safety_Center/ PPC_VTE_Prophylaxis.pdf. Accessed January 14, 2014. 10. Guyatt G, Akl E, Crowther M, et al. Executive Summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians EvidenceBased Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):7S-47S. 11. Venous thromboembolism prophylaxis in orthopedic surgery. Effective Health Care Program Comparative Effectiveness Review. Agency for Healthcare Research and Quality. http://effectivehealthcare.ahrq.gov/index .cfm/search-for-guides-reviews-and-reports/?productid ¼999&pageaction¼displayproduct. Accessed January 14, 2014. 12. Checklist to improve patient safety. Health Research & Education Trust. http://www.hpoe.org/Reports-HPOE/ CkLists_PatientSafety.pdf. Published June 2013. Accessed January 27, 2014. 13. Surgeons report value-based decision-making process using single best practice to prevent DVT reduces hospital costs by more than $1.5 million annually [news release]. Chicago, IL: American College of Surgeons; April 10, 2013. http://www.facs.org/news/jacs/value-based -decision-0413.html. Accessed January 27, 2014. 14. Perioperative explications for the ANA Code of Ethics for Nurses. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014:21-42.
Sharon A. McNamara, MS, BSN, RN, CNOR, is a perioperative consultant and speaker and a performance improvement specialist for North Carolina Hospital Association Quality Center in Fuquay Varina, NC. Ms McNamara has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
AORN Journal j 647
D
eep vein thrombosis (DVT) is defined as a blood clot that occurs in a deep vein in the body, often in the leg or thigh1; a pulmonary embolism (PE), however, occurs when a clot breaks free and enters the arteries of the lungs.2 Both DVT and PE are forms of venous thromboembolism (VTE), and both are important health concerns.3,4 The Agency for Healthcare Research and Quality (AHRQ) reports VTE as the most common preventable cause of hospital deaths.5 The prevention of DVT and PE should be a priority for the entire health care profession. Patients who undergo surgical and other invasive procedures face increased risks that make it imperative that the perioperative RN understand DVT and PE prophylaxis, and can take an active role in DVT prevention. CAUSATIVE FACTORS AND RISK Two million patients experience some form of VTE annually, either during a hospital stay or within 30 days after discharge, and most hospitalized patients have at least one risk factor for VTE.5 Twentythree million surgeries are performed annually in the United States, and 20% of surgical patients are in a high-risk category (eg, patients undergoing hip and knee arthroplasty, patients with a hip fracture) to develop proximal DVTs, thus intensifying the importance of prevention.5 Proximal DVT is the most dangerous because it frequently leads to PE if the patient does not receive anticoagulant
prophylaxis.5 One in 10 surgical patients develops a DVT and dies; this represents more deaths than those from breast cancer, AIDS, and traffic accidents combined.5 The AHRQ estimates the costs in treatment and increased length of stay for DVT to be $10,000 and for PE to be $20,000 per patient.5 In the current financial environment and culture of patient safety, prevention is an important concept when discussing VTEs. A patient may present with a primary causative factor for DVT (eg, venous stasis, vessel-wall injury, hypercoagulability), but it is important to remember that DVT risk is elevated for all surgical patients, including children. This is because routine surgical situations, such as immobility, tissue trauma, and surgical positioning requirements, place all surgical patients at risk for DVT.6,7 Venous thromboembolism risk and coagulation status vary within the population, and coagulation status may change for an individual patient several times throughout his or her hospital experience, related to medication changes, weight, age, renal function, invasive interventions, and previous VTE prevention options.8 The Virchow triad refers to the group of risk factors that are necessary for VTE to occur: venous stasis, vessel-wall injury, and hypercoagulability. Each condition alone raises risk, but, when combined, risk escalates. Patients at high risk for venous stasis have conditions that include the elements of the Virchow triad. Examples of high-risk patients include those who
The AORN Journal is seeking contributors for the Patient Safety First column. Interested authors can contact Sharon A. McNamara, column coordinator, by sending topic ideas to [email protected]. http://dx.doi.org/10.1016/j.aorn.2014.02.001
642 j AORN Journal
May 2014
Vol 99
No 5
Ó AORN, Inc, 2014
PATIENT SAFETY FIRST n n n n n n n
n
are older than 40 years of age, have had cancer or are being treated for the cancer, have cardiac disease (eg, congestive heart failure, myocardial infarction), have been on prolonged bed rest or immobilized, have had surgery longer than 30 minutes, have varicose veins, have experienced prolonged periods of travel (eg, more than four to 10 hours in the previous eight weeks), or are pregnant or postpartum.5-10
Evaluating patients for vessel-wall injury risk includes identifying those who currently have certain risk factors or those with a history of certain risk factors, which include n n n n n n
VTE or stroke, surgery, trauma, extensive burns, cancer and its associated therapy, and the presence of a central venous catheter.5-10
Hypercoagulability risks include patients with a history of certain factors. These include n n n n n
cancer and its associated therapy, recent trauma, recent pregnancy or postpartum period, oral contraceptive use or hormone replacement therapy, and inherited or acquired thrombophilia.5-10
In addition to the above risk factors, patients who have acute medical illnesses, infectious processes, or inflammatory conditions, including inflammatory bowel disease, active rheumatic disease, sickle cell disease, or acute and chronic lung disease; are smokers; or are dehydrated also may have an increased risk for DVT. Patients with any of these risk factors exhibit a greater potential for DVT.5-10 Frequently, it is the nurse who assesses the patient, identifies the patient’s risks, categorizes the risks, and implements a DVT prevention protocol
www.aornjournal.org
or contacts the physician for an order for prophylaxis. AORN’s “Recommended practice for prevention of deep vein thrombosis”8 provides a guide for the perioperative RN to provide care for the patient and to participate in the development of a framework or protocol for VTE prevention. The recommended practices document plus a literature review, including the information from AHRQ and the American College of Chest Physicians, provide support protocols that apply to all patients but which can be individualized after the nurse performs a DVT assessment on the patient on admission and regularly throughout the patient’s hospital stay. The AORN practice recommendations help the perioperative nurse select appropriate prophylaxis by linking the patient’s VTE risk to a corresponding menu of proven options. When caring for patients with elevated risk, multidisciplinary teamwork and communication during transitions of care become very important. Hand overs among the preoperative, intraoperative, and postoperative nurses should include information about the individual patient’s primary causative factors for VTE and the surgery’s implications or effects on the patient’s risk factors. Hand-over communication also should address any interventions, either pharmacologic or mechanical, that are in place or may need to be implemented. Multidisciplinary Teamwork Convening a multidisciplinary team to develop and implement an organization-wide DVT prevention protocol should be the first step in organizing VTE prevention protocols. It is crucial that nurses be a part of any team that develops these policies, procedures, and protocols. In addition, the group should include surgeons, internists with critical care experience, anesthesia professionals, pharmacists, and hematologists. Additional participants will depend on the organization and its resources but may involve, for example, representatives from patient safety or rehabilitation areas. The protocol created by this team should be supported by evidence-based models that are risk based and AORN Journal j 643
May 2014
PATIENT SAFETY FIRST
Vol 99 No 5
that consider both mechanical and pharmacologic treatment, contraindications, and possible complications. Surgical committees and specialty societies have identified best practices, areas of controversy, and contraindications that should be considered when developing a VTE prevention protocol.5,7,9-12 After developing the protocol, health care providers should have easy access to the protocol as well as all supporting evidence. To be effective, the protocol must provide a process that is simple to apply to all patients within the organization’s scope of service. Performing a thorough patient assessment on admission and at the time of any change in clinical condition provides information necessary to determine the patient’s risk for VTE and assists health care providers in identifying the appropriate mechanical or pharmacologic prophylaxis measures needed. Identifying an individual patient’s risk factors and contraindications for mechanical or pharmacologic treatment allows practitioners to evaluate and categorize the patient’s level of risk as low, moderate, or high, and, based on the risk assessment, the physician or advanced practice nurse can then prescribe treatment. Many examples of interventions are available in the literature, but it is important for practitioners at each facility to customize interventions to the patient population served when developing a VTE protocol and order set, and for health care professionals to individualize interventions to each patient.5,9-11 To improve patient assessment and intervention reliability in the process, health care professionals should use a risk-assessment screening tool that helps them link the patient’s risk to a menu of treatment choices and a standard written order set that connects the risk assessment to a prophylaxis choice.12 As important as identifying when risk assessments must be performed, determining who will perform the assessments is key. Nurses frequently assume this role, but physicians and pharmacists complete risk assessments in some organizations through VTE trigger tools (ie, screening assessment questions that trigger further investigation). 644 j AORN Journal
Monitoring is necessary to determine whether assessments are being performed reliably and, if not, to make changes to the assessments and the personnel who perform them.12 Mechanical DVT Prophylaxis The perioperative RN should implement specific interventions when the patient is ordered to receive mechanical DVT prophylaxis. Mechanical interventions are used throughout the perioperative period. n
Preoperatively, measures may include n use of graduated compression stockings or n intermittent pneumatic compression devices (IPCD). n Intraoperatively, measures may include n inspection and maintenance of any preoperatively applied mechanical DVT prophylaxis; n assessment of preoperatively applied IPCD for correct size; n careful positioning; and n repositioning, if possible, during procedures that last more than four hours. n In the immediate postoperative period, measures may include n early ambulation; n active and passive foot and ankle exercises, which create natural muscle compression of the legs’ venous system; and 8 n reducing venous stasis. Graduated compression stockings and IPCDs reduce venous stasis and improve venous return from the legs. Graduated compression stockings perform this function by constant compression of the calves, and IPCDs perform this function by sequentially and intermittently compressing a sleeve that encompasses the patient’s feet, calves, or entire legs to mimic the natural action of the leg muscles. They are available in foot, knee, and thigh sleeves that may be inflated as a single unit or sequentially. Nurses should apply IPCDs according to manufacturer’s written instructions for use and should properly fit the IPCDs to the
PATIENT SAFETY FIRST individual patient. The VTE protocol should specify when the nurse should disconnect the IPCDs from the pumps and when to perform skin assessment. There are contraindications and possible complications in the use of mechanical DVT prophylaxis. It is important that the nurse consider these when performing the patient’s risk assessment and when making treatment decisions. Contraindications include n
n
n n n
conditions that affect the lower extremities (eg, arteriosclerosis, peripheral vascular disease, neuropathy, dermatitis, cellulitis, infections, injuries, surgical sites); conditions that compromise lower extremity blood flow (eg, severe arteriosclerosis, ischemic vascular disease, massive leg edema); sensitivity to latex, if wraps and tubing are not latex free; severe congestive heart failure; and thigh circumference that exceeds the limit of the instructions for use.5,8
Possible complications from the use of mechanical DVT prophylaxis could include
www.aornjournal.org
assessment of the patient and surgical procedure. The RN must verify that the order for pharmacologic treatment is unambiguous and accurate before administration of the medication. The seven rights of medication practices should be observed (ie, right patient, right medication, right dose, right time, right route, right indication, right documentation).8 Attention to the correct concentration of these medications is an important safety concern. It also is important that the RN knows the weight of the patient and any known allergies. Assessing contraindications for the use of prophylactic pharmacologic intervention in the individual patient is key for the RN to identify to help ensure positive outcomes. Use of pharmacologic methods for VTE prophylaxis has proven to be safe and effective if individualized to the patient, and is cost effective.10,11,13 Nursing knowledge of contraindications and complications for pharmacologic VTE prophylaxis is important to patient safety. Contraindications to the use of pharmacologic prophylaxis include n n n
n
n
n
n
compartment syndrome, latex sensitivity or allergy, n peroneal nerve injury or palsy, and 5,8 n skin injury.
n n
Pharmacologic DVT Prophylaxis Pharmacologic prophylaxis (ie, the use of medications to alter coagulation) is very complex and is a medical responsibility. The physician must make the decision to use pharmacologic prophylaxis based on the patient’s risk factors, anticipated surgery, and contraindications, and he or she should not rely on standardized orders or protocols but should use a framework that guides the development of an individualized plan for each patient.5,7,9-11 The pharmacologic framework may include various medication options (enoxaparin, heparin, unfractionated heparin, warfarin, fondaparinux) and dosages, choices are based on the risk
complex trauma; recent hemorrhage; infective endocarditis; ocular, neurologic, or other recent surgery; pregnancy; recent intracranial, gastric, or genitourinary bleeding; and recent (ie, within 24 hours) lumbar or neuraxial anesthesia.5,8
Complications of pharmacologic prophylaxis may include n n n n n n n n
bleeding, compartment syndrome, hematoma formation, heparin-induced thrombocytopenia, osteoporosis or osteopenia, skin necrosis, thrombocytopenia, and urticaria at the injection site.5,8
Pharmacists are key decision support personnel for VTE protocols, especially when patients have
AORN Journal j 645
May 2014
PATIENT SAFETY FIRST
Vol 99 No 5
contraindications to pharmacologic treatments, and they are important members of the multidisciplinary team for planning, implementation, and day-to-day clinical care. The pharmacist is a valuable resource to physicians and nurses, and is important to the success of the VTE prevention program and the pharmacologic safety of the patient.
n
NURSING IMPLICATIONS Nurses often become key practitioners in implementing new or updated practices. It is important to communicate upcoming changes and educate care providers about the changes to facilitate frontline staff members having what they need to successfully implement change. This aspect of the VTE prevention initiative may involve educators providing the initial VTE education and prevention protocol competency evaluations. Educators can use stories of previous patients who experienced a VTE and required additional treatment or readmission to help motivate personnel and make the assessment process real.12 Educating the patient and his or her family members, and engaging them in VTE prevention and the treatment plan are important nursing interventions. This information helps the patient and his or her family members understand and identify potential complications (eg, leg pain, swelling, unexplained shortness of breath, wheezing, chest pain, palpitations, anxiety, sweating, coughing up blood), the importance of compliance, and the correct usage of mechanical and pharmacologic prophylaxis measures as well as the necessary information to report to the physician. Incorporating “teach back” methods into the education process to determine whether the patient understands the material being taught is an additional skill that nurses can use.9 Patient and family member education about VTE prevention should include
n
n
current and future risk factors; n the importance of staying hydrated; n signs and symptoms of VTE;
646 j AORN Journal
n n n
reasons to avoid constrictive clothing, sitting with legs crossed or knees bent, or sitting or standing for long periods; reasons to elevate the legs when sitting; explanations of passive and active exercises for the lower extremities; directions on how to perform frequent coughing and deep-breathing exercises if the patient is confined to bed; and an explanation of the physiology of blood flow and clot formation.8,9
Documentation of nursing interventions and education should include the patient assessment, care plan, nursing diagnosis, desired outcomes and interventions, and evaluations of the patient’s response to care.7 The development of a VTE protocol, order set, and risk-assessment tool should help the nurse provide comprehensive documentation. Collaboration with information technology personnel can facilitate acquiring documentation tools and inclusion of hard stops (ie, when mandatory information is required, the computer program does not allow the user to continue until the information is provided) for ordering in the electronic medical record. Information technology personnel also may be able to design programs or filters to identify patients who are at risk for VTE via fields already submitted to the patient’s electronic medical record and to automatically flag patients at various risk levels.9 IMPLEMENTATION The development team should create a quality improvement plan for sustaining the protocol that describes how compliance to the protocol will be tracked, by whom, and to whom compliance will be reported. This should take place before implementing any changes so that the reporting structure and level of accountability are built into the system. The communication plan for quality improvement processes should include staff members and physicians as well as individuals who are high enough in the organization to elicit accountability from all
PATIENT SAFETY FIRST levels. Implementation should include hospitalspecific VTE data to highlight the need for improving VTE prevention. The protocol team should create an investigation process that includes a defect analysis on all VTEs so that team members can learn the common causes of VTEs as well as identify any special cause variations that occur. In addition to collaborating on the prevention protocols, nurses also may be responsible for developing an equipment purchase and distribution plan for sequential compression power packs and stockings to minimize treatment delays.9 To do this effectively, an understanding of VTE prevention and the available products is needed. CONCLUSION The participation of the nurse in VTE initiatives and prevention is imperative. Perioperative nurses have an ethical obligation to “participate in establishing, maintaining, and improving health care environments and to the provision of quality health care consistent with the values of the profession through individual and collective action.”14(p36) The perioperative nurse plays an important role as an autonomous patient advocate whose ability to assess the patient and his or her environment, implement and evaluate treatment, assess the potential implications involved in complex patient positioning, and ensure accurate hand overs between patient care areas by communicating clinical information that will assist in the prevention of VTE. The nurse’s critical thinking skills and knowledge will facilitate leading efforts to prevent VTE to protect the patient and create a culture of safety. References 1. What is deep vein thrombosis? National Heart, Lung and Blood Institute. http://www.nhlbi.nih.gov/health/health -topics/topics/dvt/. Accessed January 13, 2014. 2. What is a pulmonary embolism? National Heart, Lung and Blood Institute. http://www.nhlbi.nih.gov/health/ health-topics/topics/pe/. Accessed January 13, 2014. 3. Centers for Disease Control and Prevention. Venous thromboembolism in adult hospitalized patients e United States, 2007-2009. MMWR Morb Mortal Wkly Rep. 2012; 61(22):401-404. http://www.cdc.gov/mmwr/preview/ mmwrhtml/mm6122a1.htm. Accessed January 16, 2014.
www.aornjournal.org
4. Beckman GE, Hopper C, Critchley SE, Ortel TL. Venous thromboembolism: a public health concern. Am J Prev Med. 2010;38(4 Suppl):S495-S499. 5. Preventing hospital acquired venous thromboembolism: a guide for effective quality improvement. Agency for Healthcare Research and Quality. http://www.ahrq.gov/ professionals/quality-patient-safety/patient-safety-resources/ resources/vtguide/index.html. Accessed January 14, 2014. 6. Ahonen J. Day surgery and thromboembolic complications: time for structured assessment and prophylaxis. Curr Opin Anaesthesiol. 2007;20(6):535-539. 7. Rawat A, Huynh TT, Peden EK, Kougias P, Lin PH. Primary prophylaxis of venous thromboembolism in surgical patients. Vasc Endovasc Surg. 2008;42(3):205-216. 8. Recommended practices for prevention of deep vein thrombosis. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014: 421-430. 9. Failure mode and effects analysis venous thromboembolism prophylaxis. Partnership for Patient Care. ECRI Institute Healthcare Improvement Foundation. 2007. https://www.ecri.org/Documents/Patient_Safety_Center/ PPC_VTE_Prophylaxis.pdf. Accessed January 14, 2014. 10. Guyatt G, Akl E, Crowther M, et al. Executive Summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians EvidenceBased Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):7S-47S. 11. Venous thromboembolism prophylaxis in orthopedic surgery. Effective Health Care Program Comparative Effectiveness Review. Agency for Healthcare Research and Quality. http://effectivehealthcare.ahrq.gov/index .cfm/search-for-guides-reviews-and-reports/?productid ¼999&pageaction¼displayproduct. Accessed January 14, 2014. 12. Checklist to improve patient safety. Health Research & Education Trust. http://www.hpoe.org/Reports-HPOE/ CkLists_PatientSafety.pdf. Published June 2013. Accessed January 27, 2014. 13. Surgeons report value-based decision-making process using single best practice to prevent DVT reduces hospital costs by more than $1.5 million annually [news release]. Chicago, IL: American College of Surgeons; April 10, 2013. http://www.facs.org/news/jacs/value-based -decision-0413.html. Accessed January 27, 2014. 14. Perioperative explications for the ANA Code of Ethics for Nurses. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014:21-42.
Sharon A. McNamara, MS, BSN, RN, CNOR, is a perioperative consultant and speaker and a performance improvement specialist for North Carolina Hospital Association Quality Center in Fuquay Varina, NC. Ms McNamara has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
AORN Journal j 647
