Welcome to the latest key papers and publications focussing mainly on venous thromboembolism and VTE champions in the nursing profession and the role they play as part of a clinical team.
Please click on the links below and enter your OpenAthens username and password to download the full text or contact the library at esth.hirsonlibrary@nhs.net to request the full text.Venous thromboembolism prophylaxis: The role of the nurse in changing practice and saving lives
Abstract: Background: Venous thromboembolism (VTE) predominantly afflicts surgical and medical patients in an acute hospital setting. Responsibility for VTE risk assessment and appropriate prophylaxis to prevent this major health burden rests with a variety of clinical staff. All too frequently, however, patients do not undergo VTE risk assessment on admission. This is regardless of the fact that a number are at risk for VTE, receive no prophylaxis and unknowingly are at risk of serious adverse events including death. Objective(s): The broad aims of this paper is to provide evidence based information on VTE and to report on the rate of appropriate VTE prophylaxis pre and post nursing educational sessions. Setting(s): This paper describes a nurse led initiative undertaken at a tertiary level acute care facility in Queensland. Subjects: A clinical audit was conducted on 2,063 hospitalised inpatients. Primary argument: Nurses who are empowered through evidence based education sessions can take responsibility for VTE risk assessment of all admitted patients and ensure appropriate VTE prophylaxis is provided. The rates for appropriate prophylaxis in admitted patients at risk of VTE increased from 27% to 85% (Setting(s): This paper describes a nurse led initiative undertaken at a tertiary level acute care facility in Queensland. Subjects: A clinical audit was conducted on 2,063 hospitalised inpatients. Primary argument: Nurses who are empowered through evidence based education sessions can take responsibility for VTE risk assessment of all admitted patients and ensure appropriate VTE prophylaxis is provided. The rates for appropriate prophylaxis in admitted patients at risk of VTE increased from 27% to 85% (Conclusion(s): Nurses who are committed to VTE risk assessment and prophylaxis have the ability to contribute significantly to the reduction of VTE and its subsequent complications.
Source: Collins R. Australian Journal of Advanced Nursing, March-May 2010; 27(3): 83-89
Evaluation of hospital nurses' perceived knowledge and practices of venous thromboembolism assessment and prevention
Abstract: Venous thromboembolism (VTE) is a preventable cause of hospital death. Bedside registered nurses (RNs) are a key group that can be the first to recognize risks of patients in acute care settings. The purpose of this study was to identify bedside hospital RNs' perceived knowledge of VTE, their assessment practices, their self-efficacy in conducting VTE prevention care, and their perceived barriers to performing VTE risk assessment. An anonymous web-based survey on VTE risk assessment and prevention was conducted with RNs who provided direct patient care at two hospitals. RNs who were not directly involved in bedside patient care such as managers and educators were excluded. A total of 221 RNs completed the survey. Most participants rated their overall knowledge of VTE risk assessment between "good" (44%) and "fair" (28%). VTE assessment frequencies performed by participants varied widely. Participants reported high confidence in their ability to educate patients and families about VTE symptoms, prevention, and treatments. Participants were least confident in their own ability to conduct a thorough VTE risk assessment. Greater self-reported VTE knowledge was associated with greater VTE assessment frequency and self-efficacy for VTE preventive care. The most common perceived barriers in performing VTE risk assessment were lack of knowledge (21%) and lack of time (21%). The findings demonstrate a substantial need for focused education about VTE prevention for hospital nurses and support for hospital systems to monitor VTE care. Despite the Joint Commission emphasis on VTE risk assessment in all hospitalized patients, there remains a gap between current, evidence-based recommendations for VTE prevention and reported nursing practices.
Source: Lee J.A. Journal of Vascular Nursing, March 2014; 32(1): 18-24
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e-Learning interventions for nurses to prevent venous thromboembolism in patients: A realist review
Abstract: Aim: To synthesise published literature exploring online venous thromboembolism (VTE) prevention education programmes to identify, test and refine a program theory supporting translation of knowledge into practice for registered nurses. Background(s): Venous thromboembolism is a leading cause of preventable morbidity and mortality in hospitalised patients. Successful implementation of prevention strategies can be impeded by a lack of education and translation of knowledge to practice. Continuing professional development programs using e-learning platforms are increasingly common, however, there is little published literature exploring effective translation of such education to practice. Design(s): Realist Review. Method(s): Searches were conducted in seven healthcare databases prior to July 2020 and updated in March 2022. Synthesis was informed by the unified theory of acceptance and use of technology (UTAUT) model and followed stages of a realist review outlined by Pawson et al. The results were reported according to the RAMESES publication standards. Result(s): Eight context-mechanism-outcome combinations were identified to explain engagement, completion and adoption of VTE e-learning into practice. Mechanisms included valuing content as relevant to practice, having confidence in the ability to use the technology and empowerment to enact change based on learning. Contextual factors that may constrain the completion of learning include the support of managers and organisations through time, and the availability of resources. Conclusion(s): Translation of e-learning is critical to ensure clinical excellence. This realist review demonstrated the varying mechanisms contributing to engagement, completion and adoption of learning. These illustrate the complex nature of education for professional development. It demonstrates that the UTAUT model is suitable for guiding the design, implementation and adoption of e-learning programmes. Relevance to clinical practice: This review used a common clinical practice (VTE) to provide a program theory that can guide clinical educators to understand mechanisms which can facilitate engagement with, completion and adoption of e-learning into practice by nurses. No patient or public contribution: The focus of this realist review was on e-learning for registered nurses. As such, no patient or public contribution was sought or given in the development, progress and writing of the submitted manuscript.
Source: Dyke E.V. Journal of Clinical Nursing, Nov 2022; Online ahead of print
What is a thrombosis nurse specialist – and could you be one?: The role involves delivering evidence-based care in preventing, diagnosing and treating venous thromboembolism and providing anticoagulation for patients
Abstract: Thrombosis nurse specialists provide safe and effective anticoagulation for patients who have, or are at risk of, thrombotic or embolic disease.
Source: Lorusso E. Nursing Standard, Nov 2022; 37(11): 69-70
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Venous thromboembolism: have we made headway?
Abstract: Venous thromboembolism (VTE) is a primary cause of preventable hospital death. The need for effective VTE prophylaxis has been recognized by the Surgical Care Improvement Program (SCIP) and the Joint Commission, which is offering VTE prevention as a core measure set, starting October 1, 2009. The adoption of SCIP VTE measures and mandate to publicly report these rates offers the opportunity to improve the use of prophylaxis in surgical patients and reduce VTE-related morbidity, mortality, and costs. Essential to this reduction is a team approach to implementing real-time interventions. Crucial to the success of the team is early identification of each patient's VTE risk and a mechanism to provide key information to ensure that the physician prescribes appropriate prophylaxis. In addition, it may be the nurse who is responsible for ensuring that a patient receives the appropriate prophylaxis, as well as being the first clinician to observe the clinical signs of a VTE event.
Source: Fitzgerald J. Orthopedic Nursing, Jul-Aug 2010; 29(4): 226-34
Using an Institute Model to Reduce the Incidence of Venous Thromboembolism Within a Large Hospital System
Abstract: Internal benchmarking showed that the Orthopedic Institute had an above average rate of venous thromboembolism (VTE) along with other institutes. The Orthopedic VTE Quality Team was assigned to investigate opportunities for improvement to share with other institutes. To investigate the issues and barriers to the administration of chemical and mechanical VTE prophylaxis, data collection included real-time point prevalence study, physician and nursing surveys, and electronic medical record audits. The results of the data collection indicated inconsistencies in nursing and patient care. Therefore a VTE policy and VTE educational poster was developed. In conjunction, nursing education will be completed to describe the best practice for sequential compression devices and anticoagulant therapies and documentation. The physician will be notified for refusals on either mechanical or chemical prophylaxis.
Source: Leininger S. Critical Care Nursing Quarterly, Oct-Dec 2022; 45(4): 307-316
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Safe anticoagulant management for patients taking warfarin
Abstract: Patients taking the anticoagulant warfarin to treat or prevent blood clots need regular international normalised ratio blood tests to ensure their blood levels remain within a set therapeutic range. If patients go above or below this range, the safety and efficacy of the drug is compromised. Warfarin's narrow therapeutic index makes it difficult for some patients to remain in a set therapeutic range. This article describes an intervention whereby specialist anticoagulant nurses work with patients who have poor warfarin management to help them switch to new oral anticoagulants or increase their time in range to improve safety and quality of life.
Source: Roberts M. Nursing Times, Dec 2019; 115(12): 52-55
Reducing Rates of Perioperative Deep Vein Thrombosis and Pulmonary Emboli in Hip and Knee Arthroplasty Patients: A Quality Improvement Project
Abstract: Objective: To decrease the rates of venous thromboembolism (VTE) associated with total knee arthroplasty (TKA) and total hip arthroplasty (THA), evaluate the effectiveness of the current practice of deep vein thrombosis (DVT) and pulmonary embolism (PE) prophylaxis, and improve patient care and recovery following surgery. Methods: A multidisciplinary team of surgeons, intensivists, cardiologists, nurses, pharmacists, physical therapists, hospital quality and safety directors, and senior hospital administration was formed to study trends in care, review best practices, identify root causes of suboptimal performance, and implement improvements. Results: DVT/PE rates associated with TKA/THA decreased nearly 60% over 2 years to a rate of 4.8 per 1000 discharges. Enoxaparin dosing has been sustained at 94% of patients, and 88% of patients experience early mobilization. Conclusion: Multidisciplinary teams are capable of effecting sustained improvements in patient care and outcomes when paired with lean management practices and a commitment to quality improvement. Collective efforts towards education, removal of barriers to carry out best practices, and having physicians champion the prevention of DVT/PE led to a clinically significant and sustained improvement in patient outcomes.
Source: Long L. MDedge|Journal of Clinical Outcomes Management, Jan-Feb 2019; 26(1): 19-25
Progressive Mobility Protocol Reduces Venous Thromboembolism Rate in Trauma Intensive Care Patients: A Quality Improvement Project
Abstract: The intensive care unit (ICU) trauma population is at high risk for complications associated with immobility. The purpose of this project was to compare ICU trauma patient outcomes before and after implementation of a structured progressive mobility (PM) protocol. Outcomes included hospital and ICU stays, ventilator days, falls, respiratory failure, pneumonia, or venous thromboembolism (VTE). In the preintervention cohort, physical therapy (PT) consults were placed 53% of the time. This rose to more than 90% during the postintervention period. PT consults seen within 24 hr rose from a baseline 23% pre- to 74% -- 94% in the 2 highest compliance postintervention months. On average, 40% of patients were daily determined to be too unstable for mobility per protocol guidelines -- most often owing to elevated intracranial pressure. During PM sessions, there were no adverse events (i.e., extubation, hypoxia, fall). There were no significant differences in clinical outcomes between the 2 cohorts regarding hospital and ICU stays, average ventilator days, mortality, falls, respiratory failure, or pneumonia overall or within ventilated patients specifically. There was, however, a difference in the incidence of VTE between the preintervention cohort (21%) and postintervention cohort (7.5%) (p =.0004). A PM protocol for ICU trauma patients is safe and may reduce patient deconditioning and VTE complications in this high-risk population. Multidisciplinary commitment, daily protocol reinforcement, and active engagement of patients/families are the cornerstones to success in this ICU PM program.
Source: Booth K. Journal of Trauma Nursing, Set-Oct 2016; 23(5): 284-9
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"Keep Calm and Stop the Clot": The impact of a nurse-driven change project
Abstract: The impact of a nurse-driven change project.
Source: Aberg T. Nursing Management, Apr 2018; 49(4): 9-12
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Improving VTE prophylaxis adherence among hospitalized adolescents using Human-Centered Design
Abstract: Background/problem statement: Venous thromboembolism (VTE) is the leading cause of preventable hospital mortality in the United States; however, compliance with VTE prophylaxis is poor. Most materials for education about VTE prophylaxis are oriented toward adults rather than adolescents, for whom VTE risks are lower and prophylaxis indications differ. We hypothesized that educational materials for adolescents could improve compliance with VTE prophylaxis, reduce nurse burden for initiating and maintaining VTE prevention practices, and reduce practice variation by standardizing the conversation between clinicians and patients. Methods: A multidisciplinary team including physicians, nurses, quality experts, communication designers, service designers, and medical students applied a human-centered design (HCD) process to define, iteratively prototype, and test education tools for nurses assigned to adolescents. We piloted a suite of six educational tools for adolescent VTE prophylaxis to fit into the existing hospital workflow. Results: An in-room poster was selected after 85% of nurses responded favorably to this intervention. Adolescent adherence with Intermittent Pneumatic Compression Device increased from 69% to 79%, attaining the benchmark goal of 78%. Staff reported greater confidence in educating adolescent patients after the intervention: 62% of nurses and 72% of residents. Conclusion: An HCD process helped nurses improve VTE prophylaxis for adolescents with an in-room poster and messaging strategy. Engaging staff in the design increased receptivity and adoption. The piloted materials also helped to create an environment of shared priority among the clinicians.
Source: Journal of Patient Safety and Risk Management, Aug 2021; 26(4): 172-178
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Improving compliance to clinical practice guidelines with a multifaceted quality improvement program for the prevention of venous thromboembolic disease in nonsurgical patients
Abstract: Objective: To evaluate the change in compliance to thromboprophylaxis guidelines before and after the implementation of a multifaceted patient safety program. Design: Longitudinal before and after study. Setting: Teaching hospital, Hospital Universitario San Ignacio, Bogotá (Colombia). Participants: Adult nonsurgical hospitalized patients. Intervention: A multifaceted program for the prevention of venous thromboembolic (VTE) disease among adult nonsurgical hospitalized patients. The strategies of the program included (i) update and communication of thromboprophylaxis guidelines, (ii) the implementation of risk-assessment tools in electronic medical records, (iii) nursing staff activities and (iv) education to health personnel and patients for maintenance of the program. Main Outcome Measure: Appropriate use of thromboprophylaxis. Results: 221 and 236 patients were evaluated in the pre- and postimplementation periods, respectively. Global appropriate thromboprophylaxis prescription went from 74.66 to 82.6% (P = 0.064). Adequate thromboprophylaxis in high-risk patients did not increase significantly (77.70 vs 80.62%, P = 0.528), but a significant reduction in inappropriate thromboprophylaxis formulation in low-risk patients was found, decreasing from 20.55 to 5.26% (P = 0.005). Conclusions: Implementing a quality improvement multifaceted program improves the formulation of adequate thromboprophylaxis. Reducing the inappropriate prescription of VTE prophylaxis in patients at low risk of thrombosis can lead to a reduction in bleeding complications and a better use of economic and human resources.
Source: Kim S. International Journal of Quality in Health Care, Jun 2020; 32(5): 319-324
Implementing a Clinical Decision Tool to Improve Oncologic Venous Thromboembolism Management
Abstract: Background: Cancer patients with venous thromboembolic (VTE) disease are complex, and many factors must be considered when initiating anticoagulation management. Clinical decision support systems can aid in decision-making by utilizing guidelines at the point of care. Objectives: The purpose of our project was to develop, implement, and evaluate an electronic clinical decision tool (CDT) utilizing evidence-based guidelines to aid in decision-making for adult oncologic patients who present with new VTE to symptom care clinics. Methods: We compared a pre-intervention group of patients who were prescribed anticoagulation (n = 98) with two post-intervention groups: CDT applied (n = 96) and not applied (n = 46). Outcomes included whether the CDT anticoagulation recommendations were followed and if the tool was perceived to be helpful or improve confidence in initiating management for new VTE by the SCC advanced practitioners and physicians. Results: There was no significant difference between the pre- and post-intervention groups in how many of the CDT anticoagulation recommendations were followed (68.8% pre-intervention, 60.8% postintervention tool applied, and 63.5% post-intervention tool not applied; χ² 2, N = 161] = .921, p = .631). However, the tool was found to be helpful and improved confidence of the providers in initiating management for new VTE (pre median = 3, interquartile range IQR] = 2, 3.5; post median = 3, IQR 3, 4; p = .033). Conclusion: This CDT provided evidence-based anticoagulation recommendations for cancer-associated VTE and enhanced familiarity with the standard of care. Further development of the CDT will be required to account for situations that resulted in deviation from the recommendations.
Source: Majeed J. Journal of the Advanced Practitioner in Oncology, May 2022; 13(4): 382-391
Guideline Implementation: Prevention of Venous Thromboembolism
Abstract: Abstract: Venous thromboembolism (VTE) is a serious and costly complication of surgery. Many cases of health care–associated VTE could be prevented with the use of evidenced‐based interventions. Perioperative nurses are in a position to advocate for patients by assessing each patient’s risk for VTE and implementing preventive measures, such as administering anticoagulants as ordered and correctly applying graduated compression stockings and intermittent pneumatic compression devices. The updated AORN “Guideline for prevention of venous thromboembolism” provides guidance to perioperative team members for developing and implementing a protocol for VTE prevention. This article focuses on key points of the guideline that address preoperative patient assessment for VTE and bleeding risk, safe use of pharmacologic and mechanical prophylaxis, patient education on prevention and signs and symptoms of VTE, and a quality management program to evaluate VTE prophylaxis outcomes and protocol compliance. Perioperative nurses should review the complete guideline for additional information and for guidance when writing and updating policies and procedures.
Source: Link T. AORN Journal, Jun 2018; 107(6): 737-748
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Crew Resource Management and VTE Prophylaxis in Surgery: A Quality Improvement Initiative
Abstract: Despite the availability of safe and effective prophylaxis, appropriate use of venous thromboembolism (VTE) prophylaxis in surgical patients remains suboptimal. Multifaceted quality improvement (QI) activities are needed for sustained improvement at the individual institution level. This work describes a QI initiative for VTE prophylaxis in surgery that combined clinical education with Crew Resource Management (CRM)--a set of principles and techniques for communication, teamwork, and error avoidance used in the aviation industry. Surveys of clinicians participating in the initiative demonstrated immediate and retained confidence and increased knowledge in identifying process-related factors leading to errors, applying CRM to patient care, and identifying VTE prophylaxis candidates and guideline-recommended prophylaxis regimens. Reviews of patient charts preinitiative and postinitiative demonstrated performance improvement in meeting guideline recommendations for the timing, inpatient duration, and use of VTE prophylaxis beyond discharge. This new model joins continuing medical education with CRM to improve the appropriate use of VTE prophylaxis in surgery.
Source: Tapson V.F. American Journal of Medical Quality, Nov-Dec 2011; 26(6): 423-32
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Barriers to Providing VTE Chemoprophylaxis to Hospitalized Patients: A Nursing-Focused Qualitative Evaluation
Abstract: Background: Venous thromboembolism (VTE) is a serious medical condition that results in preventable morbidity and mortality.Objectives: The objective of this study was to identify nursing-related barriers to administration of VTE chemoprophylaxis to hospitalized patients.Design: This was a qualitative study including nurses from five inpatient units at one hospital.Methods: Observations were conducted on five units to gain insight into the process for administering chemoprophylaxis. Focus group interviews were conducted with nurses and were audio-recorded, transcribed verbatim, and analyzed using the Theoretical Domains Framework to identify barriers to providing VTE chemoprophylaxis.Results: We conducted 14 focus group interviews with nurses from five inpatient units to assess nurses' perceptions of barriers to administration of VTE chemoprophylaxis. The barriers identified included nurses' misconceptions that ambulating patients did not require chemoprophylaxis, nurses' uncertainty when counseling patients on the importance of chemoprophylaxis, and a lack of comparative data for nurses regarding their specific refusal rates. Conclusions: Multiple factors act as barriers to patients receiving VTE chemoprophylaxis. These barriers are often modifiable targets for quality improvement. There is a need to focus on behavior changes that will remove or minimize barriers and equip nurses to ensure administration of VTE chemoprophylaxis by engaging patients in their care.
Source: Kreutzer L. Journal of Hospital Medicine, Nov 2019; 14(11): 668-672
Assessment of an Intervention to Reduce Aspirin Prescribing for Patients Receiving Warfarin for Anticoagulation
Abstract: Key Points: Question: Is it possible to reduce excess aspirin (acetylsalicylic acid) use among patients treated with warfarin, and is reducing excess aspirin use associated with improved clinical outcomes? Findings: This multicenter quality improvement study of 6738 adults taking warfarin for atrial fibrillation and/or venous thromboembolism without an apparent indication for concomitant aspirin found that an anticoagulation clinic–based aspirin deimplementation intervention was associated with a significant acceleration of a preexisting decrease in excess aspirin use. Reducing aspirin use was associated with significantly less bleeding and health care use; no increase in thrombotic outcomes was observed. Meaning: This study suggests that it is possible to reduce aspirin use without a clear indication and that this effort may be associated with improved clinical outcomes. Importance: For some patients receiving warfarin, adding aspirin (acetylsalicylic acid) increases bleeding risk with unclear treatment benefit. Reducing excess aspirin use could be associated with improved clinical outcomes. Objective: To assess changes in aspirin use, bleeding, and thrombosis event rates among patients treated with warfarin. Design, Setting, and Participants: This pre-post observational quality improvement study was conducted from January 1, 2010, to December 31, 2019, at a 6-center quality improvement collaborative in Michigan among 6738 adults taking warfarin for atrial fibrillation and/or venous thromboembolism without an apparent indication for concomitant aspirin. Statistical analysis was conducted from November 26, 2020, to June 14, 2021. Intervention: Primary care professionals for patients taking aspirin were asked whether an ongoing combination aspirin and warfarin treatment was indicated. If not, then aspirin was discontinued with the approval of the managing clinician. Main Outcomes and Measures: Outcomes were assessed before and after intervention for the primary analysis and before and after 24 months before the intervention (when rates of aspirin use first began to decrease) for the secondary analysis. Outcomes included the rate of aspirin use, bleeding, and thrombotic outcomes. An interrupted time series analysis assessed cumulative monthly event rates over time. Results: A total of 6738 patients treated with warfarin (3160 men 46.9%]; mean SD] age, 62.8 16.2] years) were followed up for a median of 6.7 months (IQR, 3.2-19.3 months). Aspirin use decreased slightly from a baseline mean use of 29.4% (95% CI, 28.9%-29.9%) to 27.1% (95% CI, 26.1%-28.0%) during the 24 months before the intervention (P <.001 for slope before and after 24 months before the intervention) with an accelerated decrease after the intervention (mean aspirin use, 15.7%; 95% CI, 14.8%-16.8%; P =.001 for slope before and after intervention). In the primary analysis, the intervention was associated with a significant decrease in major bleeding events per month (preintervention, 0.31%; 95% CI, 0.27%-0.34%; postintervention, 0.21%; 95% CI, 0.14%-0.28%; P =.03 for difference in slope before and after intervention). No change was observed in mean percentage of patients having a thrombotic event from before to after the intervention (0.21% vs 0.24%; P =.34 for difference in slope). In the secondary analysis, reducing aspirin use (starting 24 months before the intervention) was associated with decreases in mean percentage of patients having any bleeding event (2.3% vs 1.5%; P =.02 for change in slope before and after 24 months before the intervention), mean percentage of patients having a major bleeding event (0.31% vs 0.25%; P =.001 for change in slope before and after 24 months before the intervention), and mean percentage of patients with an emergency department visit for bleeding (0.99% vs 0.67%; P =.04 for change in slope before and after 24 months before the intervention), with no change in mean percentage of patients with a thrombotic event (0.20% vs 0.23%; P =.36 for change in slope before and after 24 months before the intervention). Conclusions and Relevance: This quality improvement intervention was associated with an acceleration of a preexisting decrease in aspirin use among patients taking warfarin for atrial fibrillation and/or venous thromboembolism without a clear indication for aspirin therapy. Reductions in aspirin use were associated with reduced bleeding. This study suggests that an anticoagulation clinic–based aspirin deimplementation intervention can improve guideline-concordant aspirin use. This quality improvement study assesses changes in aspirin use, bleeding, and thrombosis event rates among patients treated with warfarin for atrial fibrillation and/or venous thromboembolism without an apparent indication for concomitant aspirin.
Source: Schaefer J.K. JAMA Network Open, Sep 2022; 5(9): e2231973
'Adopt innovative strategies to prevent VTE in hospitals'
Abstract: Venous thromboembolism (VTE) is a major safety issue for hospital patients. Preventive measures should be implemented to reduce its associated morbidity and mortality.
Source: Bonner L. Nursing Times, Feb 2011; 107(5): 11
Adherence to Inpatient Venous Thromboembolism Prophylaxis: A Single Institution's Concurrent Review
Abstract: Hospital-acquired venous thromboembolism (VTE) affects morbidity and mortality and increases health care costs. Poor adherence to recommended prophylaxis may be a potential cause of ongoing events. This study aims to identify institutional adherence rates and barriers to optimal VTE prophylaxis. The authors performed patient and nurse interviews and a concurrent review of clinical documentation, utilizing a cloud-based, HIPAA-compliant tool, on a convenience sample of hospitalized patients. Adherence and agreement between different assessment modalities were calculated. Seventy-six patients consented for participation. Nurse documented adherence was 66% (29/44), 44% (27/61), and 89% (50/56) for mechanical, ambulatory, and chemoprophylactic prophylaxis, respectively. Patient report and nurse documentation showed moderate agreement for mechanical and no agreement for ambulatory adherence (κ = 0.51 and 0.07, respectively). Concurrent review using a cloud-based tool can provide robust, timely, and relevant information on adherence to recommended VTE prophylaxis. Iterative concurrent reviews can guide efforts to improve adherence and reduce rates of hospital-acquired VTE.
Source: Bauer T.M. American Journal of Medical Quality, Jul/Aug 2019; 34(4): 402-408
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Initiative to reduce inappropriate venous thromboembolism prophylaxis in an 11-hospital safety net system: An electronic health records-based approach
Abstract: Background: While pharmacologic prophylaxis has benefits for venous thromboembolism (VTE) prevention in high-risk patients, unnecessary use carries potential harm, including bleeding, heparin-induced thrombocytopenia, and patient discomfort, and should be avoided in low-risk patients. While many quality improvement initiatives aim to reduce underuse, successful models on reducing overuse are sparse in the literature. Objective: We aimed to create a quality improvement initiative to reduce overuse of pharmacologic VTE prophylaxis. Designs, Settings and Participants A quality improvement initiative was implemented across 11 safety net hospitals in New York City. Intervention The first electronic health record (EHR) intervention consisted of a VTE order panel that facilitated risk assessment and recommended VTE prophylaxis for high-risk patients only. The second EHR intervention used a best practice advisory that alerted clinicians when prophylaxis was ordered for a patient previously deemed?low risk.? Prescribing rates were compared through a three-segment interrupted time series linear regression design. Results: Compared to the preintervention period, the first intervention did not change the rate of total pharmacologic prophylaxis immediately after implementation (1.7% relative change, p?=?.38) or over time (slope difference of 0.20 orders per 1000 patient days, p?=?.08). Compared to the first intervention period, the second intervention led to an immediate 4.5% reduction in total pharmacologic prophylaxis (p?=?.04) but increased thereafter (slope difference of 0.24, p?=?.03) such that weekly rates at the end of the study were similar to rates prior to the second intervention.
Source: Haller M.D. Journal of Hospital Medicine, Apr 2023; Online ahead of print
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A quality improvement initiative to reduce venous thromboembolism on a gynecologic oncology service
Abstract: OBJECTIVE: To describe and evaluate the effects of implementation of a venous thromboembolism (VTE) prophylaxis quality improvement (QI) initiative on a gynecologic oncology service at a single institution. METHODS: Prior to 2018, no consensus gynecologic oncology VTE prophylaxis protocol existed at the authors' academic institution. Published, evidence-based guidelines were reviewed to create a standardized VTE risk stratification algorithm. Interventions to improve perioperative heparin administration and sequential compression device (SCD) compliance as well as provider/patient education efforts were introduced in January 2018. Initial efforts included nursing and patient SCD education, internal dissemination of VTE prophylaxis guidelines, and creation of a VTE 'dashboard' to track performance. During a second phase, VTE prophylaxis guidelines were reviewed and further refined, non-compliant operative cases reviewed weekly, and guidelines incorporated into the electronic medical record. Performance was measured using Tableau data software (www.tableau.com) and by separately evaluating adherence to the developed guidelines in three retrospective cancer-enriched surgical cohorts (2016-2017, 2018, 2019). RESULTS: Compared to the baseline period, we observed a reduction in VTE rate during the 2018-2019 VTE QI implementation period from 2.1% (19/905) to 1.0% (20/2015, p = 0.02) among gynecologic oncology inpatients. In the retrospective cancer-enriched cohorts, adherence to evidence based guidelines improved: 31.0% in 2016-2017, 69.1% in 2018, and 82.4% in 2019 (p < 0.001). There were no significant differences in rates of peri-operative blood transfusion, surgical site infections, hematomas, or vaginal cuff dehiscences. CONCLUSIONS: Implementation of a robust VTE prophylaxis QI initiative has resulted in improved VTE prophylaxis guideline adherence and higher rates of pre-operative heparin administration.
Source: Gonzalez R. Gynecologic Oncology, Jul 2021; 162(1): 120-127
Venous thromboembolism prophylaxis: the role of the nurse
Abstract: The work of nurses in undertaking a proactive role in the prevention of deep vein thrombosis and pulmonary embolism in hospital patients. Risk factors for thromboembolism formation, its prevalence, symptoms and diagnosis are described. Prevention using mechanical and pharmacological measures and contraindications for each are outlined.
Source: Findlay J. British journal of Nursing, Sep 2010; 19(16): 1028-32
Improving the adoption of optimal venous thromboembolism prophylaxis in critically ill patients: A process evaluation of a complex quality improvement initiative
Abstract: Purpose: This study evaluated a complex initiative to increase evidence-based use of low molecular weight heparin for venous thromboembolism prophylaxis among adult medical-surgical ICU patients. Materials and methods: This study included: quantitative survey and interviews. Participants were healthcare providers within four ICUs. Surveys collected knowledge of evidence underpinning best practice, exposure to the implementation strategies and their perceived utility, and recommendations. The interview expanded on survey topics. Descriptive statistics summarized the data and chi-squared tests were used to compare groups. Qualitative data were analyzed using a blended deductive and inductive coding approach. Results: Providers had good knowledge of the evidence (range = 58% to 94%). Pharmacist-to-physician reminders (80%), other reminders (50%), and local guidelines (50%) were the most commonly observed strategies. Local champions (76%), on-site education (74%), and computerized decision support system (69%) were perceived to be most helpful. Interviews elicited five themes: provider roles, perceptions of the implementation strategies, facilitators and barriers to uptake of best practice, and recommendations. Assessment of the implementation strategies varied by professional group. Conclusions: The findings of this process evaluation identified implementation strategies that can improve the use of evidence-informed practices, help interpret outcomes in the context of interventions and guide future quality improvement initiatives.
Source: Sauro, Khara M. Journal of Critical Care, Apr 2019; 50: 111-117
IDENTIFYING VALIDATED VENOUS THROMBOEMBOLISM RISK ASSESSMENT TOOLS: THE OFFICIAL VOICE OF PERIOPERATIVE NURSING
Abstract: Answer: The Caprini risk assessment model (RAM) is the most widely studied and validated VTE risk assessment tool for use in surgical patient populations.1'4 This tool has also been incorporated into the clinical practice guidelines for antithrombotic therapy and thrombosis prevention by the American College of Chest Physicians.5 The Caprini RAM has gone through several revisions; the 2013 version is the most current. The VTE protocol should * be evidence based, * standardize the process of assessing for risks of VTE and bleeding, * include a standardized VTE risk assessment tool, * be followed consistently throughout the health care organization, * provide clinical decision support for evidence-based VTE prophylaxis based on level of risk for VTE and bleeding at critical phases of care (eg, admission, transfer of care, postoperative period, discharge), * be easy to implement in clinical practice, * be embedded in the clinical workflow, * be audited to ensure compliance, and * be outlined in the organization's policies and procedures.7 A core component of the organization's VTE protocol is the standardized VTE risk assessment tool. Identifying both the risks for VTE and bleeding allows the health care team to determine the most appropriate prophylaxis method (eg, mechanical, pharmacologic), start time, and duration for each patient.7 The Agency for Healthcare Research and Quality, however, cautions that clinicians may perceive some point-based risk assessment models, such as the Caprini RAM, as too complex; therefore, implementation of their use should minimize the need for manual calculations by including effective automation.9 Additionally, organizational leaders should embed the VTE and bleeding risk assessments into the clinical workflow to improve reliability, clarity, and ease of use.9 Regardless of the VTE risk assessment tool chosen, experts emphasize the importance of educating clinicians on the correct use of the tool, including conducting accurate assessments and interpreting scores correctly.10 Although the use of VTE risk assessment tools can improve individual patient VTE risk identification, it does not replace the need for a thorough patient assessment and application of sound clinical judgment.
Source: Jones E. AORN Journal, Jan 2023; 117(1): 72-74
Which is the best model to assess risk for venous thromboembolism in hospitalised patients?
Abstract: What you need to know:
• Venous thromboembolism in hospitalised patients can be potentially prevented through patient
education and pharmacological thromboprophylaxis
• Risk assessment models (RAMs) help clinicians decide who should be offered pharmacological
thromboprophylaxis, but variation exists in their composition of risk factors and thresholds for high
and low risk
• Uncertainty exists over which RAM is optimal for hospitalised patients and whether any complex RAM outperforms simple criteria or subjective clinical opinion
Source: Horner D. BMJ, May 2021; 373(1106)
Guideline for Prevention of Venous Thromboembolism: The Official Voice of Perioperative Nursing
Abstract: A VTE patient questionnaire that patients fill out ahead of an in-person appointment with their provider also may be used as part of the VTE risk assessment to help decrease the time required to complete the assessment and reduce complexity of the evaluation.1,2 Although the Agency for Healthcare Research and Quality recommends that a standardized bleeding risk assessment be used to improve the reliability of VTE protocols,3 there are no bleeding risk assessment tools validated in surgical patients.4 Thus, an interdisciplinary team should design and implement a standardized bleeding risk assessment that can be performed concurrently with the VTE risk assessment.1,3 Any intraoperative events that increase the risk of VTE and bleeding (eg, longer operative time, major blood loss, placement of an immobilizing cast of a lower limb) should be discussed during the hand over.1,5 Prophylaxis A new recommendation was added to ask patients about any religious or cultural concerns they may have during the assessment for contraindications to pharmacologic prophylaxis;1 for example, heparin-based medications can have animal origins and be a concern because of religious or cultural beliefs.6 "If a patient expresses concerns with receiving an animal-derived anticoagulant medication, the perioperative nurse should notify the prescriber and the anesthesia professional, who can discuss these concerns with the patient and identify an available alternative," Jones said. Each patient should undergo an evaluation of their fall risk and have appropriate preventive measures implemented.1 Factors associated with delayed postoperative ambulation (eg, inadequate pain control, immobility, presence of tubes or drains) should be identified and minimized.1,7-9 A new recommendation also was added that foot and ankle exercises should not replace early and frequent postoperative ambulation.1 Patient Education A new recommendation was added that education on VTE prevention for patients and their caregivers should occur before surgery.1 According to Jones, beginning patient education about VTE prevention before surgery has been shown to increase patient knowledge of VTE and the use of mechanical prophylaxis postoperatively, although additional research is needed to better understand the optimal timing and technique for preoperative patient education. "Hospital-associated VTE remains a major public health concern and many VTE events can be prevented through consistent adherence to the organization's VTE protocol that includes a comprehensive VTE and bleeding risk assessment and appropriate VTE prophylaxis," Jones concluded.
Source: Croke L. AORN Journal, Dec 2022; 116(6): 4-6
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Prevention of Venous Thromboembolism: The Official Voice of Perioperative Nursing
Abstract: No abstract available.
Source: Spruce L. AORN Journal, Jan 2021; 113(1): 91-99
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Source: Collins R. Australian Journal of Advanced Nursing, March-May 2010; 27(3): 83-89
Evaluation of hospital nurses' perceived knowledge and practices of venous thromboembolism assessment and prevention
Abstract: Venous thromboembolism (VTE) is a preventable cause of hospital death. Bedside registered nurses (RNs) are a key group that can be the first to recognize risks of patients in acute care settings. The purpose of this study was to identify bedside hospital RNs' perceived knowledge of VTE, their assessment practices, their self-efficacy in conducting VTE prevention care, and their perceived barriers to performing VTE risk assessment. An anonymous web-based survey on VTE risk assessment and prevention was conducted with RNs who provided direct patient care at two hospitals. RNs who were not directly involved in bedside patient care such as managers and educators were excluded. A total of 221 RNs completed the survey. Most participants rated their overall knowledge of VTE risk assessment between "good" (44%) and "fair" (28%). VTE assessment frequencies performed by participants varied widely. Participants reported high confidence in their ability to educate patients and families about VTE symptoms, prevention, and treatments. Participants were least confident in their own ability to conduct a thorough VTE risk assessment. Greater self-reported VTE knowledge was associated with greater VTE assessment frequency and self-efficacy for VTE preventive care. The most common perceived barriers in performing VTE risk assessment were lack of knowledge (21%) and lack of time (21%). The findings demonstrate a substantial need for focused education about VTE prevention for hospital nurses and support for hospital systems to monitor VTE care. Despite the Joint Commission emphasis on VTE risk assessment in all hospitalized patients, there remains a gap between current, evidence-based recommendations for VTE prevention and reported nursing practices.
Source: Lee J.A. Journal of Vascular Nursing, March 2014; 32(1): 18-24
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e-Learning interventions for nurses to prevent venous thromboembolism in patients: A realist review
Abstract: Aim: To synthesise published literature exploring online venous thromboembolism (VTE) prevention education programmes to identify, test and refine a program theory supporting translation of knowledge into practice for registered nurses. Background(s): Venous thromboembolism is a leading cause of preventable morbidity and mortality in hospitalised patients. Successful implementation of prevention strategies can be impeded by a lack of education and translation of knowledge to practice. Continuing professional development programs using e-learning platforms are increasingly common, however, there is little published literature exploring effective translation of such education to practice. Design(s): Realist Review. Method(s): Searches were conducted in seven healthcare databases prior to July 2020 and updated in March 2022. Synthesis was informed by the unified theory of acceptance and use of technology (UTAUT) model and followed stages of a realist review outlined by Pawson et al. The results were reported according to the RAMESES publication standards. Result(s): Eight context-mechanism-outcome combinations were identified to explain engagement, completion and adoption of VTE e-learning into practice. Mechanisms included valuing content as relevant to practice, having confidence in the ability to use the technology and empowerment to enact change based on learning. Contextual factors that may constrain the completion of learning include the support of managers and organisations through time, and the availability of resources. Conclusion(s): Translation of e-learning is critical to ensure clinical excellence. This realist review demonstrated the varying mechanisms contributing to engagement, completion and adoption of learning. These illustrate the complex nature of education for professional development. It demonstrates that the UTAUT model is suitable for guiding the design, implementation and adoption of e-learning programmes. Relevance to clinical practice: This review used a common clinical practice (VTE) to provide a program theory that can guide clinical educators to understand mechanisms which can facilitate engagement with, completion and adoption of e-learning into practice by nurses. No patient or public contribution: The focus of this realist review was on e-learning for registered nurses. As such, no patient or public contribution was sought or given in the development, progress and writing of the submitted manuscript.
Source: Dyke E.V. Journal of Clinical Nursing, Nov 2022; Online ahead of print
What is a thrombosis nurse specialist – and could you be one?: The role involves delivering evidence-based care in preventing, diagnosing and treating venous thromboembolism and providing anticoagulation for patients
Abstract: Thrombosis nurse specialists provide safe and effective anticoagulation for patients who have, or are at risk of, thrombotic or embolic disease.
Source: Lorusso E. Nursing Standard, Nov 2022; 37(11): 69-70
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Venous thromboembolism: have we made headway?
Abstract: Venous thromboembolism (VTE) is a primary cause of preventable hospital death. The need for effective VTE prophylaxis has been recognized by the Surgical Care Improvement Program (SCIP) and the Joint Commission, which is offering VTE prevention as a core measure set, starting October 1, 2009. The adoption of SCIP VTE measures and mandate to publicly report these rates offers the opportunity to improve the use of prophylaxis in surgical patients and reduce VTE-related morbidity, mortality, and costs. Essential to this reduction is a team approach to implementing real-time interventions. Crucial to the success of the team is early identification of each patient's VTE risk and a mechanism to provide key information to ensure that the physician prescribes appropriate prophylaxis. In addition, it may be the nurse who is responsible for ensuring that a patient receives the appropriate prophylaxis, as well as being the first clinician to observe the clinical signs of a VTE event.
Source: Fitzgerald J. Orthopedic Nursing, Jul-Aug 2010; 29(4): 226-34
Using an Institute Model to Reduce the Incidence of Venous Thromboembolism Within a Large Hospital System
Abstract: Internal benchmarking showed that the Orthopedic Institute had an above average rate of venous thromboembolism (VTE) along with other institutes. The Orthopedic VTE Quality Team was assigned to investigate opportunities for improvement to share with other institutes. To investigate the issues and barriers to the administration of chemical and mechanical VTE prophylaxis, data collection included real-time point prevalence study, physician and nursing surveys, and electronic medical record audits. The results of the data collection indicated inconsistencies in nursing and patient care. Therefore a VTE policy and VTE educational poster was developed. In conjunction, nursing education will be completed to describe the best practice for sequential compression devices and anticoagulant therapies and documentation. The physician will be notified for refusals on either mechanical or chemical prophylaxis.
Source: Leininger S. Critical Care Nursing Quarterly, Oct-Dec 2022; 45(4): 307-316
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Safe anticoagulant management for patients taking warfarin
Abstract: Patients taking the anticoagulant warfarin to treat or prevent blood clots need regular international normalised ratio blood tests to ensure their blood levels remain within a set therapeutic range. If patients go above or below this range, the safety and efficacy of the drug is compromised. Warfarin's narrow therapeutic index makes it difficult for some patients to remain in a set therapeutic range. This article describes an intervention whereby specialist anticoagulant nurses work with patients who have poor warfarin management to help them switch to new oral anticoagulants or increase their time in range to improve safety and quality of life.
Source: Roberts M. Nursing Times, Dec 2019; 115(12): 52-55
Reducing Rates of Perioperative Deep Vein Thrombosis and Pulmonary Emboli in Hip and Knee Arthroplasty Patients: A Quality Improvement Project
Abstract: Objective: To decrease the rates of venous thromboembolism (VTE) associated with total knee arthroplasty (TKA) and total hip arthroplasty (THA), evaluate the effectiveness of the current practice of deep vein thrombosis (DVT) and pulmonary embolism (PE) prophylaxis, and improve patient care and recovery following surgery. Methods: A multidisciplinary team of surgeons, intensivists, cardiologists, nurses, pharmacists, physical therapists, hospital quality and safety directors, and senior hospital administration was formed to study trends in care, review best practices, identify root causes of suboptimal performance, and implement improvements. Results: DVT/PE rates associated with TKA/THA decreased nearly 60% over 2 years to a rate of 4.8 per 1000 discharges. Enoxaparin dosing has been sustained at 94% of patients, and 88% of patients experience early mobilization. Conclusion: Multidisciplinary teams are capable of effecting sustained improvements in patient care and outcomes when paired with lean management practices and a commitment to quality improvement. Collective efforts towards education, removal of barriers to carry out best practices, and having physicians champion the prevention of DVT/PE led to a clinically significant and sustained improvement in patient outcomes.
Source: Long L. MDedge|Journal of Clinical Outcomes Management, Jan-Feb 2019; 26(1): 19-25
Progressive Mobility Protocol Reduces Venous Thromboembolism Rate in Trauma Intensive Care Patients: A Quality Improvement Project
Abstract: The intensive care unit (ICU) trauma population is at high risk for complications associated with immobility. The purpose of this project was to compare ICU trauma patient outcomes before and after implementation of a structured progressive mobility (PM) protocol. Outcomes included hospital and ICU stays, ventilator days, falls, respiratory failure, pneumonia, or venous thromboembolism (VTE). In the preintervention cohort, physical therapy (PT) consults were placed 53% of the time. This rose to more than 90% during the postintervention period. PT consults seen within 24 hr rose from a baseline 23% pre- to 74% -- 94% in the 2 highest compliance postintervention months. On average, 40% of patients were daily determined to be too unstable for mobility per protocol guidelines -- most often owing to elevated intracranial pressure. During PM sessions, there were no adverse events (i.e., extubation, hypoxia, fall). There were no significant differences in clinical outcomes between the 2 cohorts regarding hospital and ICU stays, average ventilator days, mortality, falls, respiratory failure, or pneumonia overall or within ventilated patients specifically. There was, however, a difference in the incidence of VTE between the preintervention cohort (21%) and postintervention cohort (7.5%) (p =.0004). A PM protocol for ICU trauma patients is safe and may reduce patient deconditioning and VTE complications in this high-risk population. Multidisciplinary commitment, daily protocol reinforcement, and active engagement of patients/families are the cornerstones to success in this ICU PM program.
Source: Booth K. Journal of Trauma Nursing, Set-Oct 2016; 23(5): 284-9
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"Keep Calm and Stop the Clot": The impact of a nurse-driven change project
Abstract: The impact of a nurse-driven change project.
Source: Aberg T. Nursing Management, Apr 2018; 49(4): 9-12
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Improving VTE prophylaxis adherence among hospitalized adolescents using Human-Centered Design
Abstract: Background/problem statement: Venous thromboembolism (VTE) is the leading cause of preventable hospital mortality in the United States; however, compliance with VTE prophylaxis is poor. Most materials for education about VTE prophylaxis are oriented toward adults rather than adolescents, for whom VTE risks are lower and prophylaxis indications differ. We hypothesized that educational materials for adolescents could improve compliance with VTE prophylaxis, reduce nurse burden for initiating and maintaining VTE prevention practices, and reduce practice variation by standardizing the conversation between clinicians and patients. Methods: A multidisciplinary team including physicians, nurses, quality experts, communication designers, service designers, and medical students applied a human-centered design (HCD) process to define, iteratively prototype, and test education tools for nurses assigned to adolescents. We piloted a suite of six educational tools for adolescent VTE prophylaxis to fit into the existing hospital workflow. Results: An in-room poster was selected after 85% of nurses responded favorably to this intervention. Adolescent adherence with Intermittent Pneumatic Compression Device increased from 69% to 79%, attaining the benchmark goal of 78%. Staff reported greater confidence in educating adolescent patients after the intervention: 62% of nurses and 72% of residents. Conclusion: An HCD process helped nurses improve VTE prophylaxis for adolescents with an in-room poster and messaging strategy. Engaging staff in the design increased receptivity and adoption. The piloted materials also helped to create an environment of shared priority among the clinicians.
Source: Journal of Patient Safety and Risk Management, Aug 2021; 26(4): 172-178
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Improving compliance to clinical practice guidelines with a multifaceted quality improvement program for the prevention of venous thromboembolic disease in nonsurgical patients
Abstract: Objective: To evaluate the change in compliance to thromboprophylaxis guidelines before and after the implementation of a multifaceted patient safety program. Design: Longitudinal before and after study. Setting: Teaching hospital, Hospital Universitario San Ignacio, Bogotá (Colombia). Participants: Adult nonsurgical hospitalized patients. Intervention: A multifaceted program for the prevention of venous thromboembolic (VTE) disease among adult nonsurgical hospitalized patients. The strategies of the program included (i) update and communication of thromboprophylaxis guidelines, (ii) the implementation of risk-assessment tools in electronic medical records, (iii) nursing staff activities and (iv) education to health personnel and patients for maintenance of the program. Main Outcome Measure: Appropriate use of thromboprophylaxis. Results: 221 and 236 patients were evaluated in the pre- and postimplementation periods, respectively. Global appropriate thromboprophylaxis prescription went from 74.66 to 82.6% (P = 0.064). Adequate thromboprophylaxis in high-risk patients did not increase significantly (77.70 vs 80.62%, P = 0.528), but a significant reduction in inappropriate thromboprophylaxis formulation in low-risk patients was found, decreasing from 20.55 to 5.26% (P = 0.005). Conclusions: Implementing a quality improvement multifaceted program improves the formulation of adequate thromboprophylaxis. Reducing the inappropriate prescription of VTE prophylaxis in patients at low risk of thrombosis can lead to a reduction in bleeding complications and a better use of economic and human resources.
Source: Kim S. International Journal of Quality in Health Care, Jun 2020; 32(5): 319-324
Implementing a Clinical Decision Tool to Improve Oncologic Venous Thromboembolism Management
Abstract: Background: Cancer patients with venous thromboembolic (VTE) disease are complex, and many factors must be considered when initiating anticoagulation management. Clinical decision support systems can aid in decision-making by utilizing guidelines at the point of care. Objectives: The purpose of our project was to develop, implement, and evaluate an electronic clinical decision tool (CDT) utilizing evidence-based guidelines to aid in decision-making for adult oncologic patients who present with new VTE to symptom care clinics. Methods: We compared a pre-intervention group of patients who were prescribed anticoagulation (n = 98) with two post-intervention groups: CDT applied (n = 96) and not applied (n = 46). Outcomes included whether the CDT anticoagulation recommendations were followed and if the tool was perceived to be helpful or improve confidence in initiating management for new VTE by the SCC advanced practitioners and physicians. Results: There was no significant difference between the pre- and post-intervention groups in how many of the CDT anticoagulation recommendations were followed (68.8% pre-intervention, 60.8% postintervention tool applied, and 63.5% post-intervention tool not applied; χ² 2, N = 161] = .921, p = .631). However, the tool was found to be helpful and improved confidence of the providers in initiating management for new VTE (pre median = 3, interquartile range IQR] = 2, 3.5; post median = 3, IQR 3, 4; p = .033). Conclusion: This CDT provided evidence-based anticoagulation recommendations for cancer-associated VTE and enhanced familiarity with the standard of care. Further development of the CDT will be required to account for situations that resulted in deviation from the recommendations.
Source: Majeed J. Journal of the Advanced Practitioner in Oncology, May 2022; 13(4): 382-391
Guideline Implementation: Prevention of Venous Thromboembolism
Abstract: Abstract: Venous thromboembolism (VTE) is a serious and costly complication of surgery. Many cases of health care–associated VTE could be prevented with the use of evidenced‐based interventions. Perioperative nurses are in a position to advocate for patients by assessing each patient’s risk for VTE and implementing preventive measures, such as administering anticoagulants as ordered and correctly applying graduated compression stockings and intermittent pneumatic compression devices. The updated AORN “Guideline for prevention of venous thromboembolism” provides guidance to perioperative team members for developing and implementing a protocol for VTE prevention. This article focuses on key points of the guideline that address preoperative patient assessment for VTE and bleeding risk, safe use of pharmacologic and mechanical prophylaxis, patient education on prevention and signs and symptoms of VTE, and a quality management program to evaluate VTE prophylaxis outcomes and protocol compliance. Perioperative nurses should review the complete guideline for additional information and for guidance when writing and updating policies and procedures.
Source: Link T. AORN Journal, Jun 2018; 107(6): 737-748
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Crew Resource Management and VTE Prophylaxis in Surgery: A Quality Improvement Initiative
Abstract: Despite the availability of safe and effective prophylaxis, appropriate use of venous thromboembolism (VTE) prophylaxis in surgical patients remains suboptimal. Multifaceted quality improvement (QI) activities are needed for sustained improvement at the individual institution level. This work describes a QI initiative for VTE prophylaxis in surgery that combined clinical education with Crew Resource Management (CRM)--a set of principles and techniques for communication, teamwork, and error avoidance used in the aviation industry. Surveys of clinicians participating in the initiative demonstrated immediate and retained confidence and increased knowledge in identifying process-related factors leading to errors, applying CRM to patient care, and identifying VTE prophylaxis candidates and guideline-recommended prophylaxis regimens. Reviews of patient charts preinitiative and postinitiative demonstrated performance improvement in meeting guideline recommendations for the timing, inpatient duration, and use of VTE prophylaxis beyond discharge. This new model joins continuing medical education with CRM to improve the appropriate use of VTE prophylaxis in surgery.
Source: Tapson V.F. American Journal of Medical Quality, Nov-Dec 2011; 26(6): 423-32
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Barriers to Providing VTE Chemoprophylaxis to Hospitalized Patients: A Nursing-Focused Qualitative Evaluation
Abstract: Background: Venous thromboembolism (VTE) is a serious medical condition that results in preventable morbidity and mortality.Objectives: The objective of this study was to identify nursing-related barriers to administration of VTE chemoprophylaxis to hospitalized patients.Design: This was a qualitative study including nurses from five inpatient units at one hospital.Methods: Observations were conducted on five units to gain insight into the process for administering chemoprophylaxis. Focus group interviews were conducted with nurses and were audio-recorded, transcribed verbatim, and analyzed using the Theoretical Domains Framework to identify barriers to providing VTE chemoprophylaxis.Results: We conducted 14 focus group interviews with nurses from five inpatient units to assess nurses' perceptions of barriers to administration of VTE chemoprophylaxis. The barriers identified included nurses' misconceptions that ambulating patients did not require chemoprophylaxis, nurses' uncertainty when counseling patients on the importance of chemoprophylaxis, and a lack of comparative data for nurses regarding their specific refusal rates. Conclusions: Multiple factors act as barriers to patients receiving VTE chemoprophylaxis. These barriers are often modifiable targets for quality improvement. There is a need to focus on behavior changes that will remove or minimize barriers and equip nurses to ensure administration of VTE chemoprophylaxis by engaging patients in their care.
Source: Kreutzer L. Journal of Hospital Medicine, Nov 2019; 14(11): 668-672
Assessment of an Intervention to Reduce Aspirin Prescribing for Patients Receiving Warfarin for Anticoagulation
Abstract: Key Points: Question: Is it possible to reduce excess aspirin (acetylsalicylic acid) use among patients treated with warfarin, and is reducing excess aspirin use associated with improved clinical outcomes? Findings: This multicenter quality improvement study of 6738 adults taking warfarin for atrial fibrillation and/or venous thromboembolism without an apparent indication for concomitant aspirin found that an anticoagulation clinic–based aspirin deimplementation intervention was associated with a significant acceleration of a preexisting decrease in excess aspirin use. Reducing aspirin use was associated with significantly less bleeding and health care use; no increase in thrombotic outcomes was observed. Meaning: This study suggests that it is possible to reduce aspirin use without a clear indication and that this effort may be associated with improved clinical outcomes. Importance: For some patients receiving warfarin, adding aspirin (acetylsalicylic acid) increases bleeding risk with unclear treatment benefit. Reducing excess aspirin use could be associated with improved clinical outcomes. Objective: To assess changes in aspirin use, bleeding, and thrombosis event rates among patients treated with warfarin. Design, Setting, and Participants: This pre-post observational quality improvement study was conducted from January 1, 2010, to December 31, 2019, at a 6-center quality improvement collaborative in Michigan among 6738 adults taking warfarin for atrial fibrillation and/or venous thromboembolism without an apparent indication for concomitant aspirin. Statistical analysis was conducted from November 26, 2020, to June 14, 2021. Intervention: Primary care professionals for patients taking aspirin were asked whether an ongoing combination aspirin and warfarin treatment was indicated. If not, then aspirin was discontinued with the approval of the managing clinician. Main Outcomes and Measures: Outcomes were assessed before and after intervention for the primary analysis and before and after 24 months before the intervention (when rates of aspirin use first began to decrease) for the secondary analysis. Outcomes included the rate of aspirin use, bleeding, and thrombotic outcomes. An interrupted time series analysis assessed cumulative monthly event rates over time. Results: A total of 6738 patients treated with warfarin (3160 men 46.9%]; mean SD] age, 62.8 16.2] years) were followed up for a median of 6.7 months (IQR, 3.2-19.3 months). Aspirin use decreased slightly from a baseline mean use of 29.4% (95% CI, 28.9%-29.9%) to 27.1% (95% CI, 26.1%-28.0%) during the 24 months before the intervention (P <.001 for slope before and after 24 months before the intervention) with an accelerated decrease after the intervention (mean aspirin use, 15.7%; 95% CI, 14.8%-16.8%; P =.001 for slope before and after intervention). In the primary analysis, the intervention was associated with a significant decrease in major bleeding events per month (preintervention, 0.31%; 95% CI, 0.27%-0.34%; postintervention, 0.21%; 95% CI, 0.14%-0.28%; P =.03 for difference in slope before and after intervention). No change was observed in mean percentage of patients having a thrombotic event from before to after the intervention (0.21% vs 0.24%; P =.34 for difference in slope). In the secondary analysis, reducing aspirin use (starting 24 months before the intervention) was associated with decreases in mean percentage of patients having any bleeding event (2.3% vs 1.5%; P =.02 for change in slope before and after 24 months before the intervention), mean percentage of patients having a major bleeding event (0.31% vs 0.25%; P =.001 for change in slope before and after 24 months before the intervention), and mean percentage of patients with an emergency department visit for bleeding (0.99% vs 0.67%; P =.04 for change in slope before and after 24 months before the intervention), with no change in mean percentage of patients with a thrombotic event (0.20% vs 0.23%; P =.36 for change in slope before and after 24 months before the intervention). Conclusions and Relevance: This quality improvement intervention was associated with an acceleration of a preexisting decrease in aspirin use among patients taking warfarin for atrial fibrillation and/or venous thromboembolism without a clear indication for aspirin therapy. Reductions in aspirin use were associated with reduced bleeding. This study suggests that an anticoagulation clinic–based aspirin deimplementation intervention can improve guideline-concordant aspirin use. This quality improvement study assesses changes in aspirin use, bleeding, and thrombosis event rates among patients treated with warfarin for atrial fibrillation and/or venous thromboembolism without an apparent indication for concomitant aspirin.
Source: Schaefer J.K. JAMA Network Open, Sep 2022; 5(9): e2231973
'Adopt innovative strategies to prevent VTE in hospitals'
Abstract: Venous thromboembolism (VTE) is a major safety issue for hospital patients. Preventive measures should be implemented to reduce its associated morbidity and mortality.
Source: Bonner L. Nursing Times, Feb 2011; 107(5): 11
Adherence to Inpatient Venous Thromboembolism Prophylaxis: A Single Institution's Concurrent Review
Abstract: Hospital-acquired venous thromboembolism (VTE) affects morbidity and mortality and increases health care costs. Poor adherence to recommended prophylaxis may be a potential cause of ongoing events. This study aims to identify institutional adherence rates and barriers to optimal VTE prophylaxis. The authors performed patient and nurse interviews and a concurrent review of clinical documentation, utilizing a cloud-based, HIPAA-compliant tool, on a convenience sample of hospitalized patients. Adherence and agreement between different assessment modalities were calculated. Seventy-six patients consented for participation. Nurse documented adherence was 66% (29/44), 44% (27/61), and 89% (50/56) for mechanical, ambulatory, and chemoprophylactic prophylaxis, respectively. Patient report and nurse documentation showed moderate agreement for mechanical and no agreement for ambulatory adherence (κ = 0.51 and 0.07, respectively). Concurrent review using a cloud-based tool can provide robust, timely, and relevant information on adherence to recommended VTE prophylaxis. Iterative concurrent reviews can guide efforts to improve adherence and reduce rates of hospital-acquired VTE.
Source: Bauer T.M. American Journal of Medical Quality, Jul/Aug 2019; 34(4): 402-408
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Initiative to reduce inappropriate venous thromboembolism prophylaxis in an 11-hospital safety net system: An electronic health records-based approach
Abstract: Background: While pharmacologic prophylaxis has benefits for venous thromboembolism (VTE) prevention in high-risk patients, unnecessary use carries potential harm, including bleeding, heparin-induced thrombocytopenia, and patient discomfort, and should be avoided in low-risk patients. While many quality improvement initiatives aim to reduce underuse, successful models on reducing overuse are sparse in the literature. Objective: We aimed to create a quality improvement initiative to reduce overuse of pharmacologic VTE prophylaxis. Designs, Settings and Participants A quality improvement initiative was implemented across 11 safety net hospitals in New York City. Intervention The first electronic health record (EHR) intervention consisted of a VTE order panel that facilitated risk assessment and recommended VTE prophylaxis for high-risk patients only. The second EHR intervention used a best practice advisory that alerted clinicians when prophylaxis was ordered for a patient previously deemed?low risk.? Prescribing rates were compared through a three-segment interrupted time series linear regression design. Results: Compared to the preintervention period, the first intervention did not change the rate of total pharmacologic prophylaxis immediately after implementation (1.7% relative change, p?=?.38) or over time (slope difference of 0.20 orders per 1000 patient days, p?=?.08). Compared to the first intervention period, the second intervention led to an immediate 4.5% reduction in total pharmacologic prophylaxis (p?=?.04) but increased thereafter (slope difference of 0.24, p?=?.03) such that weekly rates at the end of the study were similar to rates prior to the second intervention.
Source: Haller M.D. Journal of Hospital Medicine, Apr 2023; Online ahead of print
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A quality improvement initiative to reduce venous thromboembolism on a gynecologic oncology service
Abstract: OBJECTIVE: To describe and evaluate the effects of implementation of a venous thromboembolism (VTE) prophylaxis quality improvement (QI) initiative on a gynecologic oncology service at a single institution. METHODS: Prior to 2018, no consensus gynecologic oncology VTE prophylaxis protocol existed at the authors' academic institution. Published, evidence-based guidelines were reviewed to create a standardized VTE risk stratification algorithm. Interventions to improve perioperative heparin administration and sequential compression device (SCD) compliance as well as provider/patient education efforts were introduced in January 2018. Initial efforts included nursing and patient SCD education, internal dissemination of VTE prophylaxis guidelines, and creation of a VTE 'dashboard' to track performance. During a second phase, VTE prophylaxis guidelines were reviewed and further refined, non-compliant operative cases reviewed weekly, and guidelines incorporated into the electronic medical record. Performance was measured using Tableau data software (www.tableau.com) and by separately evaluating adherence to the developed guidelines in three retrospective cancer-enriched surgical cohorts (2016-2017, 2018, 2019). RESULTS: Compared to the baseline period, we observed a reduction in VTE rate during the 2018-2019 VTE QI implementation period from 2.1% (19/905) to 1.0% (20/2015, p = 0.02) among gynecologic oncology inpatients. In the retrospective cancer-enriched cohorts, adherence to evidence based guidelines improved: 31.0% in 2016-2017, 69.1% in 2018, and 82.4% in 2019 (p < 0.001). There were no significant differences in rates of peri-operative blood transfusion, surgical site infections, hematomas, or vaginal cuff dehiscences. CONCLUSIONS: Implementation of a robust VTE prophylaxis QI initiative has resulted in improved VTE prophylaxis guideline adherence and higher rates of pre-operative heparin administration.
Source: Gonzalez R. Gynecologic Oncology, Jul 2021; 162(1): 120-127
Venous thromboembolism prophylaxis: the role of the nurse
Abstract: The work of nurses in undertaking a proactive role in the prevention of deep vein thrombosis and pulmonary embolism in hospital patients. Risk factors for thromboembolism formation, its prevalence, symptoms and diagnosis are described. Prevention using mechanical and pharmacological measures and contraindications for each are outlined.
Source: Findlay J. British journal of Nursing, Sep 2010; 19(16): 1028-32
Improving the adoption of optimal venous thromboembolism prophylaxis in critically ill patients: A process evaluation of a complex quality improvement initiative
Abstract: Purpose: This study evaluated a complex initiative to increase evidence-based use of low molecular weight heparin for venous thromboembolism prophylaxis among adult medical-surgical ICU patients. Materials and methods: This study included: quantitative survey and interviews. Participants were healthcare providers within four ICUs. Surveys collected knowledge of evidence underpinning best practice, exposure to the implementation strategies and their perceived utility, and recommendations. The interview expanded on survey topics. Descriptive statistics summarized the data and chi-squared tests were used to compare groups. Qualitative data were analyzed using a blended deductive and inductive coding approach. Results: Providers had good knowledge of the evidence (range = 58% to 94%). Pharmacist-to-physician reminders (80%), other reminders (50%), and local guidelines (50%) were the most commonly observed strategies. Local champions (76%), on-site education (74%), and computerized decision support system (69%) were perceived to be most helpful. Interviews elicited five themes: provider roles, perceptions of the implementation strategies, facilitators and barriers to uptake of best practice, and recommendations. Assessment of the implementation strategies varied by professional group. Conclusions: The findings of this process evaluation identified implementation strategies that can improve the use of evidence-informed practices, help interpret outcomes in the context of interventions and guide future quality improvement initiatives.
Source: Sauro, Khara M. Journal of Critical Care, Apr 2019; 50: 111-117
IDENTIFYING VALIDATED VENOUS THROMBOEMBOLISM RISK ASSESSMENT TOOLS: THE OFFICIAL VOICE OF PERIOPERATIVE NURSING
Abstract: Answer: The Caprini risk assessment model (RAM) is the most widely studied and validated VTE risk assessment tool for use in surgical patient populations.1'4 This tool has also been incorporated into the clinical practice guidelines for antithrombotic therapy and thrombosis prevention by the American College of Chest Physicians.5 The Caprini RAM has gone through several revisions; the 2013 version is the most current. The VTE protocol should * be evidence based, * standardize the process of assessing for risks of VTE and bleeding, * include a standardized VTE risk assessment tool, * be followed consistently throughout the health care organization, * provide clinical decision support for evidence-based VTE prophylaxis based on level of risk for VTE and bleeding at critical phases of care (eg, admission, transfer of care, postoperative period, discharge), * be easy to implement in clinical practice, * be embedded in the clinical workflow, * be audited to ensure compliance, and * be outlined in the organization's policies and procedures.7 A core component of the organization's VTE protocol is the standardized VTE risk assessment tool. Identifying both the risks for VTE and bleeding allows the health care team to determine the most appropriate prophylaxis method (eg, mechanical, pharmacologic), start time, and duration for each patient.7 The Agency for Healthcare Research and Quality, however, cautions that clinicians may perceive some point-based risk assessment models, such as the Caprini RAM, as too complex; therefore, implementation of their use should minimize the need for manual calculations by including effective automation.9 Additionally, organizational leaders should embed the VTE and bleeding risk assessments into the clinical workflow to improve reliability, clarity, and ease of use.9 Regardless of the VTE risk assessment tool chosen, experts emphasize the importance of educating clinicians on the correct use of the tool, including conducting accurate assessments and interpreting scores correctly.10 Although the use of VTE risk assessment tools can improve individual patient VTE risk identification, it does not replace the need for a thorough patient assessment and application of sound clinical judgment.
Source: Jones E. AORN Journal, Jan 2023; 117(1): 72-74
Which is the best model to assess risk for venous thromboembolism in hospitalised patients?
Abstract: What you need to know:
• Venous thromboembolism in hospitalised patients can be potentially prevented through patient
education and pharmacological thromboprophylaxis
• Risk assessment models (RAMs) help clinicians decide who should be offered pharmacological
thromboprophylaxis, but variation exists in their composition of risk factors and thresholds for high
and low risk
• Uncertainty exists over which RAM is optimal for hospitalised patients and whether any complex RAM outperforms simple criteria or subjective clinical opinion
Source: Horner D. BMJ, May 2021; 373(1106)
Guideline for Prevention of Venous Thromboembolism: The Official Voice of Perioperative Nursing
Abstract: A VTE patient questionnaire that patients fill out ahead of an in-person appointment with their provider also may be used as part of the VTE risk assessment to help decrease the time required to complete the assessment and reduce complexity of the evaluation.1,2 Although the Agency for Healthcare Research and Quality recommends that a standardized bleeding risk assessment be used to improve the reliability of VTE protocols,3 there are no bleeding risk assessment tools validated in surgical patients.4 Thus, an interdisciplinary team should design and implement a standardized bleeding risk assessment that can be performed concurrently with the VTE risk assessment.1,3 Any intraoperative events that increase the risk of VTE and bleeding (eg, longer operative time, major blood loss, placement of an immobilizing cast of a lower limb) should be discussed during the hand over.1,5 Prophylaxis A new recommendation was added to ask patients about any religious or cultural concerns they may have during the assessment for contraindications to pharmacologic prophylaxis;1 for example, heparin-based medications can have animal origins and be a concern because of religious or cultural beliefs.6 "If a patient expresses concerns with receiving an animal-derived anticoagulant medication, the perioperative nurse should notify the prescriber and the anesthesia professional, who can discuss these concerns with the patient and identify an available alternative," Jones said. Each patient should undergo an evaluation of their fall risk and have appropriate preventive measures implemented.1 Factors associated with delayed postoperative ambulation (eg, inadequate pain control, immobility, presence of tubes or drains) should be identified and minimized.1,7-9 A new recommendation also was added that foot and ankle exercises should not replace early and frequent postoperative ambulation.1 Patient Education A new recommendation was added that education on VTE prevention for patients and their caregivers should occur before surgery.1 According to Jones, beginning patient education about VTE prevention before surgery has been shown to increase patient knowledge of VTE and the use of mechanical prophylaxis postoperatively, although additional research is needed to better understand the optimal timing and technique for preoperative patient education. "Hospital-associated VTE remains a major public health concern and many VTE events can be prevented through consistent adherence to the organization's VTE protocol that includes a comprehensive VTE and bleeding risk assessment and appropriate VTE prophylaxis," Jones concluded.
Source: Croke L. AORN Journal, Dec 2022; 116(6): 4-6
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Prevention of Venous Thromboembolism: The Official Voice of Perioperative Nursing
Abstract: No abstract available.
Source: Spruce L. AORN Journal, Jan 2021; 113(1): 91-99
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