preventing vte in surgical patients

Preventing VTE in Surgical Patients

Today’s Topics• The common sense science of VTE prevention• Brief history of VTE prevention techniques• High yield methods of preventing VTEs in

surgical patients• A glance at the reporting requirements for VTE• Understanding your needs: A series of polls

Why Are We Focusing In Surgery?

Common Sense Science: Venous Thromboembolism (VTE)• When blood clots form in the vein and form a

mass• Two types:

– Deep Vein Thrombosis (DVT): occurs in leg veins (clot that forms in the deep veins of the body)

– Pulmonary Embolism – occurs when a clot detaches from the vessel and travels to the lungs and lodges within the pulmonary arteries

• DVT + PE = VTE

Common Sense Science Continued

• ~ 300,000-600,000 Americans develop VTE each year

• 60,000-100,000 die each year from VTE• Annual cost of care is estimated at $1.5

billion• About two-thirds of all VTE events are related

to hospitalization• 40% or more of hospital associated VTE is

preventable through prophylaxis U.S. Department of Health and Human Services. The Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism: 2008. Office of the Surgeon General and the National Heart, Lung, and Blood Institute of the National Institutes of Health; 2008. Available at: http://accpstorage.org/chest08/bestOF/SurgeonGeneralsReport.pdf. Accessed July 31, 2009.

Venous Thromboembolism: A Brief History

Rudolf Carl Virchow1821-1902

Virchow’s TriadStasis of blood flow (blood slows down)

Injury to the vein State of the body(Hypercoagulability)

VTE Main Risk Factors• Increasing age

(risk rises steadily from age 40)

• Prolonged/restricted mobility • Cancer and cancer therapy• Cardiac problems• Systemic lupus

erythematous• Infection• Microalbuminuria associated

with ESRD• Stroke• Nephrotic syndrome

• Trauma• Inflammatory bowel syndrome• Atherscelerosis • History of DVT or PE• Inherited or acquired

predisposition to clotting• Obesity• Pregnancy and postpartum

period• Oral contraceptive or hormone

replacement with estrogen• Varicose veins

The Greatest Risks for VTE• The trauma of surgery itself• Prolonged/restricted mobility• Length of the surgical procedure

The Most Important Question to Ask

“Is this patient going to be in bed for a long time?”

Surgical Patients at Risk for VTE

Risk Level Patient Population

Highest• Undergoing hip or knee surgery• With multiple risk factors• With major trauma

High • Older than 60 years• Patents ages 40-60 years with additional risk factors

Moderate • Additional risk factors undergoing minor surgery• 40-60 years with no additional risk factors

Low • Younger than 40 years with no additional risk factors undergoing minor surgery

Prophylaxis Options

Pharmacological Options

• Low-dose unfractionated heparin (LDUH)

• Low molecular weight heparin (LMWH) or

• Factor Xa Antagonist• Warfarin• Oral Factor Xa Inhibitor

(Rivaroxaban)

Non-Pharmacological/

Mechanical Options• Intermittent pneumatic

compression (IPC)• Graduated compression

stockings (GCS)• Venous foot pump (VFP)

Preventing VTE Is Complicated(Slide 1 of 3)

Hight, Henrietta. Venous Thromboembolism & Prophylaxis in the Surgical Patient. FMQI. http://www.hsag.com/App_Resources/Documents/FMQAI_SCIP_VTE_LearningModule.pdf. 27 June 2013

Preventing VTE Is Complicated(Slide 2 of 3)

Hight, Henrietta. Venous Thromboembolism & Prophylaxis in the Surgical Patient. FMQI. http://www.hsag.com/App_Resources/Documents/FMQAI_SCIP_VTE_LearningModule.pdf. 27 June 2013

Preventing VTE Is Complicated(Slide 3 of 3)

Hight, Henrietta. Venous Thromboembolism & Prophylaxis in the Surgical Patient. FMQI. http://www.hsag.com/App_Resources/Documents/FMQAI_SCIP_VTE_LearningModule.pdf. 27 June 2013

Sample Order Set

Sample order sets are available at:

http://www.fmqai.com/library/attachment-library/

VTERiskAssessmentTools.pdf

Work within a Specialty

Surgical Care Improvement Project (SCIP) MeasuresVTE Measure 1:

Surgery patients with recommended venous

thromboembolism (VTE) prophylaxis

ordered anytime from hospital arrival to 24

hours after Anesthesia End Time.

VTE Measure 2:Surgery patients who received appropriate

venous thromboembolism (VTE) prophylaxis

within 24 hours prior to Anesthesia Start Time

to 24 hours after Anesthesia End Time.

Centers for Medicare & Medicaid Services (CMS). The Joint Commission. Specifications Manual for National Hospital Inpatient Quality Measures. Version 3.1a. Revised November 6, 2009; 135-177 [SCIP-VTE 1-1 – SCIP-VTE 2-23]. QualityNet Web site. Available at: http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier4&cid=1228749003528. Accessed March 8, 2010.

Joint Commission Measures•The number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission

VTE-1Venous Thromboembolism

Prophylaxis

•The number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after the initial admission (or transfer) to the Intensive Care Unit (ICU) or surgery end date for surgeries that start the day of or the day after ICU admission (or transfer).

VTE-2Intensive Care Unit VTE

•The number of patients diagnosed with confirmed VTE who received an overlap of parenteral (intravenous [IV] or subcutaneous [subcu]) anticoagulation and warfarin therapy,

VTE-3VTE Patients with

Anticoagulation Overlap Therapy

•The number of patients diagnosed with confirmed VTE who received intravenous (IV) UFH therapy dosages AND had their platelet counts monitored using defined parameters such as a nomogram or protocol.

VTE-4VTE Patients Receiving

Unfractionated Heparin with Dosages/Platelet Count Monitored by

Protocol or Nomogram

•The number of patients diagnosed with confirmed VTE that are discharged to home, home care, court/law enforcement or home on hospice care on warfarin with written discharge instructions that address all four criteria: compliance issues, dietary advice, follow-up monitoring, and information about the potential for adverse drug reactions/interactions.

VTE-5Venous Thromboembolism

Warfarin Therapy Discharge Instructions

•The number of patients diagnosed with confirmed VTE during hospitalization (not present at admission) who did not receive VTE prophylaxis between hospital admission and the day before the VTE diagnostic testing order date.

VTE-6Hospital Acquired Potentially-

Preventable Venous Thromboembolism

Poll 1: Realistically, how often do you think that patients receiving surgery in your

facility receive treatment that fulfills some of the guidelines that we talked about?

• Never• Sometimes• Most of the time• Always

Poll 2: Additional resources from the SCHA to help us further refine our VTE prophylaxis efforts would be

helpful?• Yes• No

Poll 3:What do you see as the biggest barrier to more consistent use

of VTE guidelines?

(Open-ended question)

Take Home Messages• Preventing VTE is complicated and requires

interventions across the entire system of care• Creating guidelines/order sets by specialty is helpful• The hospital association would like to learn more

about your experiences with VTE please send an email to Lorri Gibbons at lgibbons@scha.org with:– any successes that you have had – if you have any suggestions for future topics to help

further your work in this area

?Questions

Office Hours:Wednesday 2:00-3:00

Resources

Website:www.safesurgery2015.org

Email: safesurgery2015@hsph.harvard.edu