National Patient Safety Goal 3E:

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National Patient Safety Goal 3E Anticoagulation-
Nursing Education
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Objectives

• List requirements for meeting standards for the
  National Patient Safety Goal 3E- Anticoagulation
• Identify risk factors for VTE development in
  hospitalized patients
• List 3 symptoms of DVT/PE development
• List the 3 patient risk groups for VTE
  development and 2 appropriate interventions for
  each risk group

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Purpose of National Patient Safety Goals (NPSG)

• Promote specific improvements in patient safety
• Highlight problem areas in health care
• Describe evidence-based solutions
• Focus on system-wide solutions

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National Patient Safety Goals

• Goals and Requirements are developed by experts
  from various fields
• Approved by the Joint Commission's Board in June
  2007
• New Goals may be added each year or goals may be
  continued for more than one year (ex. Med-Rec)

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National Patient Safety Goal 3E Anticoagulation

• Reduce the likelihood of patient harm with the
  use of anticoagulation (AC) therapy
• Rationale Anticoagulation therapy is a high
  risk treatment (due to complexity with dosing,
  patient compliance with treatment, monitoring)

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Risks with Anticoagulant Therapy

• Anticoagulation medications are listed as one of
  the top 5 drug classes for patient safety
  incidents¹
• Reported meds involved in harmful events² include
  Heparin, Warfarin, Enoxaparin
• Heparin errors are usually attributed to the
  non-use of programmable infusion pumps and
  non-standardized IV concentration of Heparin
  drips³

1. Cousins D et al. 2006
2. USP MedMarx data, 2005
3. Fanikos J. et al. 2004

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National Patient Safety Goal 3E Nuts Bolts

• Goal applies to the use of heparin, low molecular
  weight heparins, warfarin and other
  anticoagulants
• One year phase-in period for all hospitals with
  full implementation by January 1, 2009

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National Patient Safety Goal 3E Nuts Bolts

• Requirement for all JCAHO accredited
  institutions
• Implement a defined anticoagulation program
• Use ONLY oral Unit Dose products pre-mixed IVs
• Warfarin is dispensed for each individual patient
  with established monitoring
• Use approved protocols for the initiation
  maintenance of AC therapy

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National Patient Safety Goal 3E Nuts Bolts

• Requirement for all JCAHO accredited
  institutions
• With the use of Warfarin baseline/current INR
  is available for all patients for therapy
  adjustment
• Dietary services is notified of all pts
  receiving warfarin- food/drug interaction
  education
• Heparin IV is delivered by a programmable IV pump
  (MedNet safety pump- in drug library)
• Policy addresses baseline ongoing lab tests for
  Heparin/LMWH

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National Patient Safety Goal 3E Nuts Bolts

• Requirement for all JCAHO accredited
  institutions
• Provide education on anticoagulation therapy for
  all providers, staff, patients, and families
• Pt./family education covers specific areas
  follow-up, dietary restrictions, monitoring,
  complications, and food drug interactions
• Evaluation of Anticoagulation safety practices

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National Patient Safety Goal 3E Surveying and
Scoring

• Joint Commission will evaluate actual performance
  with standards of the Goal
• All requirements must be implemented
• Facility will be found either Compliant or Not
  Compliant
• Failure to comply will result in a Requirement
  for Improvement (RFI)

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Venous Thromboembolism (VTE) Prevention and
Anticoagulation Management
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The Problem..

• 2 million Americans will be afflicted with deep
  vein thrombosis (DVT) each year
• As many as 600,000 will subsequently develop a
  pulmonary embolism (PE)
• In about 300,000 people the PE may prove to be
  fatal
• Third most common cause of hospital-related
  deaths in the U.S.
• The most common preventable cause of hospital
  death

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Post-Test Questions
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Economic burden of VTE

• Cost of care related to VTE (cases of DVT and PE
  together) in the U.S. each year is estimated at
  1.5 billion
• Post-op thromboembolic complications add an
  average of 18,300 to the total hospital costs
  for each patient in which they happen

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Risk Factors for VTE development

• Decreased mobility
• Age (especially gt75)
• Personal history of DVT/PE or clotting disorder
• Surgery- LE joint replacement open abdominal,
  urologic, or gynecologic procedure
• Inflammatory conditions

• Current malignancy
• Estrogen therapy or pregnancy
• History of MI, CHF, COPD, or other respiratory
  failure
• Stroke lt 1 month
• Admission to the ICU
• Sepsis

Venous Thromboembolism Prophylaxis, June 2007,
ICSI
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Causes for VTE development

• Venous stasis- immobility
• Vein injury- surgery, IV therapy, phlebotomy
• Increased coagulation- cancer, inflammatory
  conditions or infectious process
• Virchows Triad

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Bed Rest!! a DVT/ PE Red Flag!!!
BEDREST
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Signs and symptoms of DVT or PE

• Pain, cramps or heaviness in affected extremity
• Parathesias- unexplained numbness or tingling
• Redness and edema of affected extremity
• Tenderness and pain in calf upon palpation
• Shortness of breath
• Chest heaviness (without cardiac explanation)
• Sense of impending doom

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DVT Prophylaxis 3 Patient Groups

• Low risk

Moderate/High risk
Highest risk
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Low risk

• Patient Group
• Age lt60
• Minor surgical procedure
• Medical patient on bedrest
• Pregnant patient or patient on oral
  contraceptives or hormone replacement
• Recommendations for prophylaxis
• Early ambulation- this means up walking in
  hallway 2-3 times per day
• SCDs while in bed

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Moderate/High risk

• Patient Group
• Age gt60
• Central venous access
• History of previous malignancy
• History of medical risk factors CHF, COPD,
  inflammatory bowel disease
• Medical patient with additional risk factors
  (CHF, COPD, Sepsis, MI)
• Major surgery planned with additional risk
  factors
• Recommendations
• Early ambulation- this means up walking in
  hallway 2-3 times per day
• SCDs while in bed
• Enoxaparin 40mg subQ every day start 12-24 hrs.
  after surgery
• If orthopedic patient- follow orthopedic
  anticoagulation protocol

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Very High Risk

• Patient Group
• Age gt75
• Elective hip or knee surgery
• Active cancer
• Hip, pelvis or leg fracture (lt1 month)
• Stroke (lt1 month)
• Admission to ICU
• Personal hx. of DVT, PE or clotting disorder
• Recommendations
• Early ambulation- this means up walking in
  hallway 2-3 times per day
• SCDs while in bed
• Enoxaparin 40mg subQ every day start 12-24 hrs.
  after surgery
• If orthopedic patient- follow orthopedic
  anticoagulation protocol

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Medical Condition Risk DVT
Condition Risk of DVT
General Medical 10-26
MI 17-34
Stroke 11-75
CHF 20-40
Medical ICU 35-42
Chest 2005 128958-969
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Prevention techniques

• Risk assessment tools-
• Providers to risk stratify patients into risk
  categories based on current diagnosis and
  previous medical history (VTE Order Set PO 1190)
• Early ambulation
• Medication prophylaxis if indicated based on
  patients VTE risk level

Venous Thromboembolism Prophylaxis, June 2007,
ICSI
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Contraindications to drug therapy

• Active, significant bleeding
• Extreme thrombocytopenia (lt50,000)
• History of heparin induced thrombocytopenia (HIT)
• Uncontrolled hypertension (SBP gt200, DBP gt120)
• Patient with bacterial endocarditis
• Patient with active hepatitis or hepatic
  insufficiency

Venous Thromboembolism Prophylaxis, June 2007,
ICSI
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New HCD DVT/PE Assessment screens

• New DVT/PE assessment screens have been built in
  HCD- will replace Homans assessment under
  muskuloskeletal body system
• This assessment is under the FLOWSHEET tab in
  HCD
• The DVT/PE assessment will be completed with all
  nursing assessments

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New HCD DVT/PE Assessment screens

• The DVT/PE assessment includes
• Calf assessment for pain, redness, warmth,
  tenderness or swelling
• Respiratory signs symptoms of SOB or difficulty
  breathing
• Includes area for documentation of MD
  NOTIFICATION if patient has any of the above
  present

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New HCD DVT/PE Assessment Screens
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New HCD DVT/PE Assessment screens
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New HCD DVT/PE Assessment screens
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New HCD DVT/PE Education screens

• New DVT/PE Education screens have been built in
  HCD (requirement to meet NPSG 3E standards)
• Documentation is under the EDUCATION tab in HCD
• The DVT/PE education will be completed and
  documented at least once during the
  hospitalization (requirement to meet NPSG 3E
  standards)
• Discharge RN must verify that DVT/PE education
  has been documented on the patient
• Enoxaparin and Coumadin Patient Education Written
  materials have been updated and will no longer
  require for nursing to document on these

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New HCD DVT/PE Education screens

• For Bethesda only- Nursing will continue to
  document on the brown border education flowsheet
• The DVT/PE education includes
• Patient education on diagnosis of DVT/PE or
  preventative information
• Documentation of consult to Dietician for
  additional drug/food interaction education
  (checking this tab will not automatically place
  order for consult- the consult must be manually
  entered)
• Patient/family education on Sx. of PE/DVT,
  medications, medication purpose, food/drug
  interactions, drug monitoring, and Lovenox demo
• Written or video education on coumadin and/or
  Lovenox

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New HCD DVT/PE Education screens
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New HCD DVT/PE Education screens
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New HCD DVT/PE Education screens
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New HCD DVT/PE Education screens
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New HCD DVT/PE Education screens
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HealthEasts work on VTE Prevention
Anticoagulant Management

• Aims (What are we trying to accomplish?)
• Reduce the incidence of DVT and PE in
  hospitalized patients by 50 in one year.
• Reduce readmissions within 31 days for DVT and PE
  by 50 in one year.
• Reduce patient harm associated with the use of
  anticoagulant therapy by 50 in one year.

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HealthEasts work on VTE Prevention
Anticoagulant Management

• Measures (How will we know that a change is an
  improvement?)
• Hospital Acquired DVT per 1000 Discharges
• Hospital Acquired PE per 1000 Discharges
• Readmissions within 31 Days with DVT per 1000
  Discharges
• Readmissions within 31 Days with PE per 1000
  Discharges
• Patient harm associated with anticoagulant
  therapy as measured by the IHI Adverse Drug Event
  Trigger Tool

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DVT Prevention

• Clinical Goals
• Adult patients (18 older) are assessed for VTE
  (DVT PE) risk within 24 hours of admission
• Appropriate pharmacological and/or mechanical
  prophylaxis begins within 24 hrs of admission
• All patients receive education regarding VTE
  signs symptoms, preventive methods
• All patients begin early and frequent ambulation

Venous Thromboembolism Prophylaxis, June 2007,
ICSI
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DVT Prevention

• Clinical Goals
• All adult medical/surgical patients with
  moderate-high or very high VTE risk receive
  anticoagulation prophylaxis unless
  contraindicated
• Reduce the risk of complications from
  pharmacologic prophylaxis.

Venous Thromboembolism Prophylaxis, June 2007,
ICSI
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DVT Prevention

• Clinical Goals
• Appropriate pharmacological and/or mechanical
  prophylaxis begins within 24 hrs of admission
• Mechanical prophylaxis is used when pharmacologic
  prophylaxis is contraindicated
• Appropriate precautions for patients receiving
  spinal or epidural anesthesia are implemented

Venous Thromboembolism Prophylaxis, June 2007,
ICSI
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Future steps

• Development of a VTE Dashboard with all system
  measures for each site
• Creation of a VTE Collaborative Practice
  Committee with participation by all site leads
• Continue assessing progress with VTE work at each
  site
• Yearly nursing, pharmacy and provider education
  (requirement for NPSG 3E)

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NPSG 3E Anticoagulation- References

• For more information, see the Joint Commission
  Website
• www.jointcommission.org
• Cousins D et al. 2006. Risk assessment of
  anticoagulation therapy. National Patient Safety
  Agency. United Kingdom
• USP MedMarx data, 2005
• Fanikos J. et al. Medication errors associated
  with anticoagulant therapy in the hospital. Am J
  Cardiol. 2004 94 532-5.
• ICSI Venous Thromboembolism Prophylaxis Fourth
  Edition-June 2007
• Chest 2005 128958-969
• Santell JP, Hicks RW, Cousins DD. MEDMARX Data
  Report  A Chart-book of 2000-2004 Findings
  from  Intensive Care Units and Radiological
  Services.  Rockville, MD USP Center for the
  Advancement of Patient Safety 2005

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Post-Test Questions

• Which of the following are requirements for
  meeting the NPSG 3E standards?
• Yearly nursing, pharmacy and provider education
• Warfarin dosing for all patients will only be
  managed by pharmacy
• Defined hospital anticoagulation management
  program
• Dietary notification of all patients receiving
  warfarin
• Answers A, C, D

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• 2. Which are risk factors for VTE development?
• a. decreased mobility, obesity, and sepsis
• b. Decreased mobility, joint, surgery, and
  history of DVT/PE
• c. decreased mobility, age gt40, and history of
  CHF
• d. Cancer, age gt40, and pregnancy

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• 3. Which are symptoms of DVT/PE development?
• a. SOB and anxiety
• b. Chest heaviness (without cardiac
  explanation) and bruising of extremity
• c. Tenderness/pain upon palpation of calf and
  SOB
• d. Redness/edema of extremity and high INR

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• 4. What are the risk factors for the Very High
  Patient group?
• a. age gt60, active cancer, and history of CHF
• b. age gt60, central venous access, and major
  abdominal surgery
• c. age gt75, bedrest, and minor surgical
  procedure
• d. age gt75, active cancer and admission to ICU

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• 5. What must be documented on discharge for
  DVT/PE patient education?
• a. diagnosis or preventative information, sx. Of
  DVT/PE, medications, and food/drug interactions
• b. diagnosis or preventative education,
  activity, diet, and food/drug interactions
• c. Home monitoring, food/drug interactions and
  follow-up appointments
• d. Food/drug interactions, outpatient therapy,
  and medications