DVT Prophylaxis and DVT Prophylaxis and Pulmonary EmbolismPulmonary Embolism

Karen Ruffin RN, MSN Ed.Karen Ruffin RN, MSN Ed.

Frequency in the USFrequency in the US Up to 2 million people are affected annually

by Venous Thromboembolism(VTE). Of those 2 million people it is estimated

that 300,000 of them will develop and die from a Pulmonary Embolism (PE).

The highest incidence of PE is with hospitalized patients.

Autopsy shows that as many as 60% of patients dying in the hospital have had a PE, but the diagnosis is being missed 70% of the time.

According to: Center for Disease Control (CDC), Department of Health and Human Services, Food and Drug Administration (FDA), The Surgeon

General

Percentage if at risk Percentage if at risk for Development of a for Development of a

VTEVTE All hospitalized patients, depending on acuity, All hospitalized patients, depending on acuity,

have between a 10%-48% of developing a VTEhave between a 10%-48% of developing a VTE Med-Surg patients placed on bed rest for a week Med-Surg patients placed on bed rest for a week

(10%-13%).(10%-13%). Patients in the MICU (29%-33%).Patients in the MICU (29%-33%). Patients with Pulmonary Disease on bed rest for 3 Patients with Pulmonary Disease on bed rest for 3

or more days (20%-26%).or more days (20%-26%). Patients in the CCU with an MI (27%-33%).Patients in the CCU with an MI (27%-33%). Patients who are asymptomatic after a CABG Patients who are asymptomatic after a CABG

(48%).(48%).

Feied, C.F. & Handler, J.A., (2008)

Mortality and Mortality and MorbidityMorbidity

Approximately 10% of the patients with an Approximately 10% of the patients with an acute PE will die with in the first 60 minutes.acute PE will die with in the first 60 minutes.

1/3 of those who live, the condition is 1/3 of those who live, the condition is diagnosed and treated.diagnosed and treated.

2/3 of the remaining patients go undiagnosed.2/3 of the remaining patients go undiagnosed. Deaths that are a result of VTE/PE were shown

to be the most common cause of preventable hospital deaths

THAT IS HUGE!THAT IS HUGE!

According to: Center for Disease Control (CDC), Department of Health and Human Services

Food and Drug Administration (FDA), The Surgeon General

Mortality and Mortality and MorbidityMorbidity

Race- Subtle population differences Race- Subtle population differences may exist, but the incidence is high in may exist, but the incidence is high in all racial groups.all racial groups.

Sex- Women only when they are Sex- Women only when they are pregnant.pregnant.

Age- Although the frequency for Age- Although the frequency for developing a PE increases with age, developing a PE increases with age, age alone is not an independent risk age alone is not an independent risk factor. It has more to do with co-factor. It has more to do with co-morbidities.morbidities.

Virchow’s TriadVirchow’s Triad

Vessel DamageVessel Damage

Vascular Vascular ConstrictionConstriction

Blood ViscosityBlood Viscosity

Vessel Damage

Endothelial cells allow blood to flow with ease through vessels.

Factor VIII or Willibrand’s Factor Conditions/lifestyles that damage

vessel walls:– Past VTE - Pressure Ulcers– Smoking - Cellulites– High Cholesterol– Varicose Veins

Vascular ConstrictionVascular Constriction

Trauma Surgery Insertion of central

line Varicose Veins Restricted Mobility Sepsis Induction MI

HF Stroke

Any external force that cause damage to the vascular system can cause slow blood flow

Blood Blood ViscosityViscosity Dehydrating Birth Control Pills High estrogen states

– Pregnancy– Postpartum

Cancer Sepsis Blood transfusions Obesity

IBS Hematologic Disorders Elevated Blood Sugar Platelet Aggregation

Physiology of ClottingPhysiology of Clotting

What is the difference What is the difference between a thrombus between a thrombus and an emboli?and an emboli?

A thrombus is a clot that is A thrombus is a clot that is stationary and a emboli is a stationary and a emboli is a thrombus that has broken off and is thrombus that has broken off and is traveling.traveling.

Most Common Cause Most Common Cause of a PEof a PE

90% are thrombi dislodged from 90% are thrombi dislodged from deep veins in the calf.deep veins in the calf.

Some originate in the pelvis, Some originate in the pelvis, particularly in pregnant women.particularly in pregnant women.

Fat embolus occur when long Fat embolus occur when long bones are broken (this is rare).bones are broken (this is rare).

What is a Pulmonary What is a Pulmonary Embolism (PE)?Embolism (PE)? Occlusion of a portion of the Occlusion of a portion of the

pulmonary vascular bed by an pulmonary vascular bed by an embolism. They can be a:embolism. They can be a:

– Thrombus (Blood Clot)Thrombus (Blood Clot)– Tissue FragmentTissue Fragment– Lipids (Fat)Lipids (Fat)– Air BubbleAir Bubble

PathophysiologyPathophysiology

Once the embolus is released into the Once the embolus is released into the blood stream they are distributed in:blood stream they are distributed in:

65%65% of the time of the time both lungsboth lungs 25%25% of the time of the time right lungright lung

▪▪ 10%10% of the time of the time left lungleft lung

▪▪ Lower lobesLower lobes are are 4 4 timestimes more more often upper lobes.often upper lobes.

PathophysiologyPathophysiology

Massive Occlusion-Massive Occlusion- an embolus that an embolus that occludes a major portion of the occludes a major portion of the pulmonary circulation.pulmonary circulation.

Embolus with InfarctionEmbolus with Infarction- An embolus - An embolus that is large enough to cause an that is large enough to cause an infarction (death) of a portion of infarction (death) of a portion of

lung lung tissuetissue Embolus without InfarctionEmbolus without Infarction- Not - Not

sever sever enough to cause permanent enough to cause permanent lung injury.lung injury.

Multiple Pulmonary EmboliMultiple Pulmonary Emboli- This can - This can be be chronic or recurrent.chronic or recurrent.

Risk Factors for DVT Risk Factors for DVT and PEand PE

Previous episode of Previous episode of thromboembolismthromboembolism

Prolonged immobilityProlonged immobility CancerCancer ObesityObesity PregnancyPregnancy Oral estrogenOral estrogen FeverFever Atrial fibrillationAtrial fibrillation

CHF, ShockCHF, Shock Varicose veinsVaricose veins Over 60 y/oOver 60 y/o Hematologic Hematologic

disordersdisorders TraumaTrauma Central LinesCentral Lines DehydrationDehydration HypovolemiaHypovolemia Surgical PatientsSurgical Patients

Prophylaxis StrategiesProphylaxis Strategies

The evidence based practice guidelines published by the ACCP in June 2008 incorporated data obtained from a comprehensive literature review of the most recent studies available.

The recommendations are broken up in to different categories from general patient populations to specific groups and conditions.

American College of Chest Physicians, (2008)

Understanding the Different Recommendation

Categories Grade 1: Benefits outweigh risk Grade 2: Less certain about the

magnitude of benefits versus risk

Grade A: High quality evidence Grade B: Moderate quality evidence Grade C: Low quality evidence

American College of Chest Physicians, (2008)

General Patient Population

Every hospital should have a formal strategy for addressing VTE prophylaxis (Grade 1A)

Mechanical methods of thromboprophylaxis should be used primarily in patients who have a high risk of bleeding (Grade 1A)

It is recommended against the use of aspirin alone as thromboprophylaxis for VTE for any group of patients (Grade 1A)

American College of Chest Physicians, (2008)

What about patients What about patients w/ a PICC line??????w/ a PICC line?????? We are a seeing We are a seeing

and increased and increased incidence of DVT incidence of DVT in patients with in patients with PICC lines.PICC lines.

How can we How can we assess for it?assess for it?

Clinical Manifestation Clinical Manifestation of PEof PE

Massive Occlusion-Massive Occlusion- Profound shock, Profound shock, hypotension, tachycardia, pulmonary hypotension, tachycardia, pulmonary hypertension, and chest pain.hypertension, and chest pain.

Embolus with Infarction-Embolus with Infarction- Pleural pain, Pleural pain, pleural friction rub, pleural effusion, pleural friction rub, pleural effusion, hemoptysis, fever, and leukocytosis.hemoptysis, fever, and leukocytosis.

Recurrent PE-Recurrent PE- Occur in individuals who Occur in individuals who have have had a history of previous had a history of previous emboli.emboli.

Applying the Nursing Applying the Nursing ProcessProcess AssessmentAssessment DiagnosisDiagnosis PlanningPlanning InterventionIntervention EvaluationEvaluation

Assessment and Assessment and SymptomsSymptoms

Homon’s signHomon’s sign H&PH&P CoughCough Sudden onset of Sudden onset of

SOBSOB AgitationAgitation LightheadnessLightheadness FaintingFainting

DizzinessDizziness SweatingSweating AnxietyAnxiety Rapid BreathingRapid Breathing TachycardiaTachycardia Air HungerAir Hunger

What are your What are your nursing diagnosis nursing diagnosis going to be???going to be???

Tell me your long and short Tell me your long and short term goals.term goals.

DiagnosticsDiagnostics

Arterial Blood Arterial Blood GasesGases

EKGEKG EchocardiogramEchocardiogram Chest x-rayChest x-ray VQ scanVQ scan Spiral CT scanSpiral CT scan Pulmonary Pulmonary

AngiogramAngiogram

Pt, ptt, INRPt, ptt, INR D-DImerD-DImer Split FibrinogenSplit Fibrinogen MRAMRA

WHAT ARE YOUR WHAT ARE YOUR INTERVENTIONS FOR INTERVENTIONS FOR YOUR STATED GOALS?YOUR STATED GOALS?

Remember to always have:Remember to always have:

AssessmentAssessment

ActionAction

PsychosocialPsychosocial

EducationEducation

For every goal!For every goal!

TreatmentTreatment

SupportiveSupportive FiltersFilters Anticoagulants/ThrombolyticsAnticoagulants/Thrombolytics

– HeparinHeparin– CoumadinCoumadin– StreptokinaseStreptokinase– RetavaseRetavase– TPATPA

SO WHAT WILL WE SO WHAT WILL WE EVALUATE AND WHY?EVALUATE AND WHY?

Cost of Prevention vs. Cost of Prevention vs. Treatment????Treatment????

V/Q scan- $1500V/Q scan- $1500 ICU bed $9000 ICU bed $9000

dayday Arterial Arterial

Angiogram- Angiogram- $3200$3200

Many other Many other realted cost????? realted cost?????

Sequential Sequential stockings- $10 stockings- $10 dayday

Heparin subq- Heparin subq- pennies a daypennies a day

Lovenox subq Lovenox subq $15 a day$15 a day

Prevention is KEYPrevention is KEY

Intermittent Pneumatic StockingsIntermittent Pneumatic Stockings– SCDSCD– TedsTeds– Early AmbulationEarly Ambulation

Low Dose AnticoagulationLow Dose Anticoagulation– HeprinHeprin– LovenoxLovenox– ArixtraArixtra

So, what does all of this mean to us?

Assessment and Documentation

We must assess if a patient is at risk for the development of a VTE

Document that assessment Communicate with the health

care team that the patient is at risk for a VTE.

Document that communication Education, Education, Education

Why are all those steps important????

The Joint Commission and the Centers for Medicare and Medicaid have implemented VTE quality measures for surgical patients which include the Surgical Care Improvement Project (SCIP 1 & SCIP 2).

SCIP 1 evaluates if patients were identified as being at risk, was prophylaxis ordered appropriately.

SCIP 2 examines if prophylaxis was actually received by patient. Surgical types include: ortho, gyn, urological, elective spine, intracraneal . Appropriate prophylaxis includes: LDUFH, Fundaparinux, LMWH, warfarin

Why are all those steps important????

The CMS has created guidelines on payment for service for healthcare providers that use evidence based practice to promote the best possible outcomes for its customers.

In 2005, section 5001(c) of the Deficit Reduction Act of 2005 (DRA) authorized the Secretary of the Department of Health and Human Services to select conditions that: 

(1) are high cost, high volume, or both; (2) are identified through ICD-9-CM coding as complicating conditions (CCs) or major complicating conditions (MCCs) that, when present as secondary diagnoses on claims, result in a higher-paying MS-DRG; and (3) are reasonably preventable through the application of evidence-based guidelines.

So what does that mean to the bedside nurse?

We must encourage all healthcare members to follow best practices as outline by creditable bodies such as the ACCP.

Our role in assisting with reimbursement for care provided is to appropriately assess our patients and determine who is at risk for VTE/PE.

Next we must communicate this information with the physicians.

Once orders are receive for thromboprophylaxis we should ensure that treatment is delivered as soon as possible or within 2 to 3 hours of receiving the orders.

The Power of Suggestion!! Don’t ever underestimate it!!!!!!!

Case StudiesCase Studies

37y/o women presented to the ER 18 37y/o women presented to the ER 18 days s/p laparotomy for lyses of days s/p laparotomy for lyses of adhesions.adhesions.

Symptoms- CP, SOB, lightheadness, Symptoms- CP, SOB, lightheadness, tachycardia.tachycardia.

She was seen by an NP and not by an She was seen by an NP and not by an MD. CBC, Cardiac Enzymes, and Chem 7 MD. CBC, Cardiac Enzymes, and Chem 7 ordered and were normal. Pt was sent ordered and were normal. Pt was sent home and told to follow up with her home and told to follow up with her primary in two days.primary in two days.

Pt. suffered a nonfatal PE that night. Pt. suffered a nonfatal PE that night. She was awarded $1,000,000.00She was awarded $1,000,000.00

Case StudyCase Study

Nurse was to D/C a pt. home. She Nurse was to D/C a pt. home. She noted a large reddened, raised, noted a large reddened, raised, warm area on the pt. right ankle. warm area on the pt. right ankle. The nurse documented it, but did not The nurse documented it, but did not notify the physician.notify the physician.

The pt. suffered a fatal PE two days The pt. suffered a fatal PE two days later. A claim was filed against the later. A claim was filed against the nurse and was settled for nurse and was settled for $4,000,000.00.$4,000,000.00.

Case StudyCase Study

Pt. was admitted with a fractured right Pt. was admitted with a fractured right hip on Sat morning. Patient was started hip on Sat morning. Patient was started on Lovenox 30mg subq daily. That order on Lovenox 30mg subq daily. That order was renew on Monday after the patient was renew on Monday after the patient had an ORIF of the right hip. The order had an ORIF of the right hip. The order was missed for 2 days. The patient was missed for 2 days. The patient suffered a non-fatal PE was transferred suffered a non-fatal PE was transferred to the ICU. The hospital stay was to the ICU. The hospital stay was extended by 3 weeks. A claim was filed extended by 3 weeks. A claim was filed against several nurses and was settled against several nurses and was settled for $1,500,000.00 and medical for $1,500,000.00 and medical expenses.expenses.

-American College of Chest Physicians, (2008). Antithrombotic and Thrombolytic Therapy: American College Of Chest Physicians Evidence –Based Clinical Practice Guidelines. 8th Edition. Volume 133/number 6 (Suppl) pages 67s-968s.

-Center for Disease Control, (2008). Are you at risk for deep vein thrombosis? Retrieved from http://www.cdc.gov/Features/Thrombosis on December 12, 2008.

-Center for Medicare and Medicaid Services, (2008). CMS improves patient safety for Medicare and Medicaid by addressing never events., CMS Manual System.

-Feied, C.F. & Handler, J.A., (2008). Pulmonary Embolism. Retrieved from eMedicine.com on December 12, 2008.

-Galson, S.K., (2008) The Surgeon General calls to action to prevent deep vein thrombosis. US Department of Health and Human Services Office of the Surgeon General. Retrieved from http://www.surgeongeneral.gov on December 12, 2008.

-National Institute for Health, (2007). What is a Deep Vein Thrombosis? Retrieved from http://www.nhlbi.nih.gov/health/dci/Diseases/Dvt on December 12, 2008.

-Sanofi-Aventis, (2008). The Coalition to Prevent Deep-Vein Thrombosis. Retrieve from, http://www.preventdvt.org on December 12, 2008.

-Sumpio, B.E., Riley, J.T, Dardik, A. (2002). Cells in focus: endothelial cell. Department of Surgery, Yale University School of Medicine. Retrieve from http://www.ncbi.nlm.nih.gov on December 12, 2008.

Now we will do an Now we will do an Evolve case study!Evolve case study!