Venous Thromboembolism (VTE) Prevention and Anticoagulation Management -Part 1: Thromboembolism

1
Venous Thromboembolism (VTE) Prevention and
Anticoagulation Management -Part 1
Thromboembolism National Patient Safety Goal 3E
Pharmacy Education
2
Objectives

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

3
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

4
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

5
Causes for VTE development

• Venous stasis- immobilization, agegt40, obesity,
  CHF, MI, general anesthesia, varicose veins
• Vein injury- trauma, surgery, CV catheter,
  history of thromboembolism (TE), cardiac
  pacemaker
• Increased coagulation- malignancy, high dose
  estrogen, pregnancy, polycythemia vera, activated
  protein C resistance, AT III deficiency,
  hyperhomocysteinemia, antiphospholipid syndrome,
  nephrotic syndrome

Virchows Triad
6
Risk Factors for VTE development

• Decreased mobility
• Increased age (especially gt75)
• Personal history of DVT/PE or clotting disorder
• Surgery- LE joint replacement open abdominal,
  urologic, or gynecologic procedure
• Inflammatory conditions
• Obesity (BMI30)

• 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
7
Bed Rest!! a DVT/ PE Red Flag!!!
BEDREST
8
Signs and symptoms of DVT or PE

• Pain, cramps or heaviness in affected extremity
• Paresthesias- 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

9
DVT Prophylaxis 3 Patient Groups

• Low risk

Moderate/High risk
Highest risk
10
Low risk

• Patient Group
• Age lt60
• Minor surgical procedure
• Medical patient on bed rest
• 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
• Sequential Compression Devices (SCDs) while in bed

11
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
• Pharmacologic prophylaxis indicated - start
  12-24 hrs. after surgery once hemostasis has
  occurred
• If orthopedic patient- follow orthopedic
  anticoagulation protocol

12
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 history of DVT, PE or clotting disorder
• Recommendations
• Early ambulation- this means up walking in
  hallway 2-3 times per day
• SCDs while in bed
• Pharmacologic prophylaxis indicated - start 12-24
  hrs. after surgery once hemostasis has occurred
• If orthopedic patient- follow orthopedic
  anticoagulation protocol

13
Procedure related risk DVT/PE
Level of Risk Calf DVT Proximal DVT Clinical PE Fatal PE
Low 2 0.4 0.2 0.002
Moderate 10-20 2-4 1-2 0.1-0.4
High 20-40 4-8 2-4 0.4-1
Very High 40-80 10-20 4-10 0.2-0.5
Increased risk up to 4-5 weeks postoperatively
ICSI Venous Thromboembolism Prophylaxis Fourth
Edition/June 2007
14
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
15
Prevention techniques

• Risk assessment tools-
• Risk stratify patients into risk categories based
  on current diagnosis and previous medical history
• Early ambulation
• Pharmacologic prophylaxis if indicated based on
  patients VTE risk level

Venous Thromboembolism Prophylaxis, June 2007,
ICSI
16
Contraindications to drug therapy

• Active, significant bleeding
• Extreme thrombocytopenia (lt50,000)
• History of heparin induced thrombocytopenia (HIT)
• Uncontrolled hypertension (SBP gt200, DBP gt120)
• Other conditions that could increase risk of
  bleeding

Venous Thromboembolism Prophylaxis, June 2007,
ICSI
17
National Patient Safety Goal 3E Anticoagulation

18
Purpose of the Joint Commissions National
Patient Safety Goals (NPSGs)

• Published by the Joint Commission annually
• 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

19
Purpose of National Patient Safety Goal 3E
Anticoagulation

• Reduce the likelihood of patient harm with the
  use of anticoagulation (AC) therapy
• Goal applies to multiple inpatient and outpatient
  settings (ambulatory care, hospitals, home care,
  long-term care, etc.)
• Rationale Anticoagulation therapy is a high
  risk treatment (due to complexity with dosing,
  patient compliance with treatment, monitoring)

20
National Patient Safety Goal 3E

• 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

21
Risks with Anticoagulant Therapy

• ACs are listed as one of the top 5 drug classes
  with patient safety incidents¹
• Reported meds involved in harmful events²
• 3 Heparin, 5 Warfarin, 11 Enoxaparin
• Heparin errors typically involve infusion pump
  and IV delivery errors³

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

22
National Patient Safety Goal 3E

• Requires that 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 anticoagulation therapy

23
National Patient Safety Goal 3E

• Requires that 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
• Policy addresses baseline ongoing lab tests for
  Heparin/LMWH

24
National Patient Safety Goal 3E

• Requires that 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.

25
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)

26
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

27
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.

28
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
29
DVT Prevention

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

Venous Thromboembolism Prophylaxis, June 2007,
ICSI
30
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
31
HealthEast Current Baseline Data

• Hospital Acquired DVT per 1000 Discharges
• Hospital Acquired PE per 1000 Discharges
• Readmissions with DVT per 1000 Discharges
• Readmissions with PE per 1000 Discharges
• Data collected during FY 07

32
Hospital Acquired DVT per 1000 Discharges
33
Hospital Acquired PE per 1000 Discharges
34
Readmissions within 31 Days with DVT per 1000
Discharges
35
Readmissions within 31 Days with PE per 1000
Discharges
36
HE Anticoagulation Safety Practices

• Standardized therapeutic Heparin premixed IV
  concentration, with infusion rate chart labels
• Smart Pump for Heparin infusion
• Restricted access to multiple strengths of
  Heparin
• Heparin Flush 100 units/ml-only strength
  available for flush use in adults on override
• Standardized weight based order sets (Heparin,
  LMWHs) with standard labs
• for orders outside of protocol, direct prescriber
  to use the order set or obtain separate labs
  orders

37
HE Anticoagulation Safety Practices

• Heparin boluses and LMWH doses dispensed by
  pharmacy as exact doses
• Do not use abbreviation for U on handwritten or
  typed orders
• Saline flush used for peripheral catheters
• Only central lines (PICC/Port-a-cath) dialysis
  catheters require Heparin flush
• Bar code technology CPOE (coming to all sites)
• Heparin-Induced Thrombocytopenia (HIT) Standard
  orders

38
HE Anticoagulation Safety Practices

• Warfarin administration at standard time of 1700
• Allows review of laboratory results (INR, etc)
• Guidelines available for standard and rapid
  reversal of warfarin
• Warfarin dispensed in exact patient doses (U/D)
• Warfarin teach packets and RN patient education
• New HED documentation available for RN
  documentation of education
• RN independent double checks of therapeutic IV
  Heparin doses

39
HE Anticoagulation Safety Practices

• Pharmacists role
• For any weight based therapeutic orders for use
  of Heparin or LMWH, verify the order, obtain an
  accurate weight in kilograms and transcribe the
  appropriate dose (if needed). Review baseline
  labs.
• Pay attention to drug interactions/duplication of
  therapy warnings in HMM (e.g. To prevent LMWH
  and Heparin duplications, significant
  interactions, etc)
• Enter INR monitoring into HMM for warfarin

40
HE Anticoagulation Safety Practices

• Pharmacists Role
• If therapeutic Heparin or LMWH hand written
  orders received
• request use of order set
• Or, obtain separate lab orders as required by the
  protocol
• Hgb
• INR and/or PTT
• Cr
• Platelets

41
Future steps..

• Development of a VTE Dashboard with all system
  measures for each site
• Creation of a VTE Collaborative Practice
  Committee with participation by representatives
  from all sites
• Continue assessing progress with VTE work at each
  site
• Annual nursing, pharmacy and provider education

42
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 128 958-969
• 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
• ISMP Medication Safety Alert Volume 12, issue 1
  Recommended Safety Improvements for
  Anticoagulants. January 11, 2007

43
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
• Nutrition Services is notified of all patients
  receiving warfarin
• all of the above
• none of the above
• a, c and d only
• b, c and d only

44
Post-Test Questions

• 2. Which are risk factors for VTE development?
• a. increase mobility, obesity, and sepsis
• b. decreased mobility, joint, surgery and
  history of DVT/PE
• c. decreased mobility, age lt40, and history of
  CHF
• d. cancer, age gt40, and pregnancy

45
Post-Test Questions

• 3. Which grouping has the correct symptoms of
  DVT/PE development?
• a. oxygen use and anxiety
• b. chest heaviness (without cardiac
  explanation) and bruising of extremity
• c. tenderness/pain upon palpation of calf and
  shortness of breath
• d. redness/edema of extremity and high INR lab
  value

46
Post-Test Questions

• 4. What are the risk factors for the Very High
  risk 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

47
Post-Test Questions

• 5. What is the pharmacists role in safety with
  anticoagulation use?
• Verify weight and dose on any therapeutic Heparin
  or low molecular weight heparin order.
• Review any drug interaction or duplication of
  therapy notices in HMM for anticoagulants and
  intervene appropriately if needed.
• Request use of standard order sets and standard
  labs when hand written orders received for
  heparin or low molecular weight heparin.
• Dispense exact dose of Heparin boluses and low
  molecular weight heparin doses.
• All of the above

48
Post-Test Questions

• 6. Which of the following is NOT part of
  Virchows triad in the development of pathogenic
  thrombus?
• hypercoaguable state
• endothelial injury
• circulatory status
• none of the above