NoCVA Hospital Engagement Network SSI/VTE Safe Surgery Collaborative. December 13, 2012

Transcription

1 NoCVA Hospital Engagement Network SSI/VTE Safe Surgery Collaborative December 13,

2 Hospital Acquired VTE Preventing a Preventable Problem It takes a commitment from ALL members of the healthcare team Paula R. Graling, DNP RN CNS CNOR Inova Multidisciplinary VTE Taskforce 2

3 Webinar Objectives 1. Explain why VTE prophylaxis is important to patient care 2. Describe the value in Risk Assessment 3. List 3 risk factors for VTE 4. Name the essential first intervention in VTE Prevention 5. List 2 ways in which to engage patients and their caregivers in VTE prevention 3

4 Why this is important VTE: A Major Source of Mortality and Morbidity 350,000 to 650,000 VTE events per year 100,000 to > 200,000 deaths per year Most are hospital related VTE is primary cause of fatality More than HIV, MVAs, Breast CA combined Equals 1 jumbo jet crash / day 10% of hospital deaths May be the #1 preventable cause Huge costs and morbidity Core Measures Surgeon General s 4 Call to Action to Prevent DVT and PE 2008 DHHS

5 Risk Factors for VTE Stasis Age > 40 Immobility CHF Stroke Paralysis Spinal Cord injury Hyperviscosity Polycythemia Severe COPD Anesthesia Obesity Varicose Veins Hypercoagulability Cancer High estrogen states Inflammatory Bowel Nephrotic Syndrome Sepsis Smoking Pregnancy Thrombophilia Endothelial Damage Surgery Prior Central lines Trauma Anderson FA Jr. & Wheeler HB. Clin Chest Med 1995;16:235. 5

6 Endorse Results Out of ~70,000 patients in 358 hospitals, appropriate prophylaxis was administered in: 58.5% of surgical patients 39.5% of medical patients Cohen, Tapson, Bergmann, et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet 2008; 371:

7 The WHY is now coming. NQF endorses measures already Public reporting and TJC measures coming soon: - Prophylaxis in place within 24 hours of admit or risk assessment / contraindication justifying it s absence - Same for critical care unit admit / transfers - Track preventable VTE CMS DVT or PE with knee or hip replacement reimbursed as though complication had not occurred 7

8 Why don t we do better? Lack of awareness or buy in of guidelines Underestimation of clot risk, overestimation of bleeding risk Lack of validated risk assessment model Translating complicated guidelines into everyday practice is difficult 8

9 Assess Patient Risk Factors In other words, every patient 9

10 Do you currently use a VTE Risk Assessment tool? Polling Question #1 A. Yes B. No 10

11 If a risk assessment tool is in place, who completes it? Polling Questions #2 A. Physician/or physician extender B. Nurse 11

12 Medicine Patients Padua Prediction Model Tool used to evaluate risk of VTE in patients with medical illness Patients at increased risk for VTE based on this model, should be placed on chemical VTE prophylaxis Any of the highest risk factors or greater than 2 of the moderate risk factors CHEST 2012 guidelines suggest using one of the following: Low-molecular weight heparin Low dose unfractionated heparin (BID or TID) Fondaparinux 12

13 Padua Prediction Model Risk Factors Highest Risk Factors Active cancer Previous VTE Reduced mobility Known thrombophilic condition Recent ( 1 month) trauma/surgery Moderate Risk Factors Elderly age (>70 years) Heart and/or respiratory failure AMI or ischemic stroke Acute infection Rheumatologic disorders Obesity (BMI 30 kg/m 2 ) Ongoing hormonal therapy 13

14 Surgical Patients Caprini Risk Assessment Tool used to evaluate the risk of VTE in surgical patients Patients with scores > 2 points should be placed on chemical VTE prophylaxis CHEST 2012 guidelines suggest using one of the following: Low-molecular weight heparin Low dose unfractionated heparin (BID or TID) 14

15 Caprini Risk Assessment Model Risk Factors (Highest and High) Highest Risk Factors (5 points) Stroke (<1 month ago) Elective arthroplasty Hip/pelvis/leg fracture Acute spinal cord injury High Risk Factors (3 points) Age 75 years old History of VTE Family history of VTE Factor V Leiden Anticardiolipin antibodies Prothrmobin 20210A Lupus anticoagulant Heparin induced thrombocytopenia Elevated serum homocysteine Other congenital or acquired thrombophilia 15

16 Caprini Risk Assessment Model Risk Factors (Moderate and Intermediate) Moderate Risk Factors (2 points) Age years old Arthroscopic surgery Malignancy Central venous access Confined to bed (>72 hours) Immobilizing plaster cast Major open surgery (> 45 minutes) Laparoscopic surgery (>45 minutes) 16 Intermediate Risk Factors (1 point) Age years old Minor surgery BMI > 25 kg/m 2 Swollen legs Varicose veins Pregnancy or postpartum History of unexplained or recurrent spontaneous abortion Oral contraceptives or hormonal replacement Sepsis (< 1 month) Serious lung disease (< 1 month) Abnormal pulmonary function Acute myocardial infarction Congestive heart failure (< 1 month) History of IBD Medical patient at bed rest

17 Basic Ingredients for Success Institutional support, will to standardize the process Designated multidisciplinary team with physician leadership Specific goals and metrics VTE Protocol guidance built into order sets Education / consensus Alerts / feedback to clinicians in real time 17

18 Enlist Key Groups / Leaders Section Heads Hospitalists (most groups receive some direct support from the hospital) Other high volume providers Find some more physician champions 18

19 Use the Powerful Anecdote and Data Look for VTE case that could have been prevented Personalize the story Enlist a patient / family to help you tell the story Get data on VTE in your medical center it occurs more often than the doctors think it does 19

20 The Essential First Intervention VTE Protocol 1) a standardized VTE risk assessment, linked to 2) a menu of appropriate prophylaxis options, plus 3) a list of contraindications to pharmacologic VTE prophylaxis Challenges: Make it easy to use ( automatic ) Make sure it captures almost all patients Trade-off between guidance and ease of use/efficiency 20

21 VTE Prevention Collaborative Prevention MD, RN, Patient/Family VTE Preventive Assessment and Care MD 1. VTE Risk Assessment on Admission Pharm orders per risk assessment SCD s per risk assessment 2. Reassessment for VTE risk by MD at change of level of care (surgery, ICU admit, pregnancy/postpartum) 3. MD Order & Pt Educ to ambulate RN 1. Ambulation evaluation (fall risk?) Document and Communicate level of activity with MD 2. Frequent ambulation at least 2 X shift AND Active Range of Motion (at least every 2 hrs while awake) 3. Give Meds as ordered- monitor INR/PT at appropriate levels 4. SCD s applied, documented and used correctly Patient /Family Education and Involvement in VTE Prevention Frequent Ambulation & ROM for Medical & Surgical Patients SCD compliance Adherence to discharge VTE Prevention Plan 21

22 Pharmacologic Prophylaxis Options Heparin 5,000 units subcutaneously q12h Consider for low weight patients (<45 kg), those with an increased risk of bleeding, and patients with renal dysfunction Heparin 5,000 units subcutaneously q8h Consider for patients with renal dysfunction Enoxaparin 40 mg subcutaneously q24h Should not be used in patients with renal dysfunction Enoxaparin 30 mg subcutaneously q12h Indicated for prophylaxis in patients undergoing total knee or total hip replacement surgery Enoxaparin 30 mg subcutaneously q24h Recommended for patients with a CrCl < 30ml/min Fondaparinux mg subcutaneously q24h Contraindicated for patients < 50kg or CrCl < 30 ml/min, recommended for history of HIT or heparin intolerance 22

23 My Patient Doesn t have Chemical Prophylaxis? Reasons patients may go without chemical VTE prophylaxis Active Bleeding Age < 18 years old Recent GI bleed (within the last 3 months) Length of stay < 2 days Thrombocytopenia (Platelets < 50,000) Comfort measures on admission Recent CNS surgery or spinal anesthesia/lumbar puncture Clinical trial patient Actively ambulating in the hall multiple times/day 23

24 Adding or Removing VTE Prevention Therapy Please assess patients for VTE prophylaxis when patient is: Admitted Transferred from another unit Returning from surgery Preparing for discharge Please evaluate risks of VTE prophylaxis when patient is: Actively bleeding Dropping hemoglobin/hematocrit Going to surgery 24

25 Role of Nursing Give anticoagulants as ordered Missed dose increases VTE risk For patients on warfarin monitor INR/PT at appropriate levels Know your patient s INR goal Check with MD before administering warfarin to patients whose INR are above goal!! Ambulation evaluation Assess for fall risk? Advance activity by pathway or protocol Ambulation ( every 2 hrs) Active Range of Motion, as adjunct 25

26 Communication with Interdisciplinary Quantify Activity How far?? How often?? Ambulate in hall Ambulate to bathroom Transfer bed to chair Refuses to get out of bed Document in Medical Record Healthcare Team 26

27 Increase Lower Extremity Perfusion Sequential Compression Devices Apply with tubing on the dorsum (top ) of the leg. Do not leave off for more than 30 minutes. Compression stockings Measure patient and select correct size Document the intervention 27

28 Engage the Patient and Caregivers Success begins on admission Patient/caregiver education on VTE risk AND prevention strategies Educate the patient using the WIIFM strategy What s in it for me?? Adult learners respond best to learning focused on why this information is important to their recovery 28

29 Preparing for Discharge Begins on admission Assess discharge needs Family /caregiver encourage support Frequent ambulation Compression stockings Participate in education on medication and side effects Discharge plans 29

30 Patient Education Drug information Micromedex Care Notes Video teaching on TV Networks Patient Education Brochures Krames patient teaching 30

31 Key Points - Recommendations QI building blocks should be used Multifaceted approach is needed VTE protocols embedded in order sets Simple risk stratification schema, based on VTE-risk groups Institution-wide if possible Don t forget patient/family engagement 31

32 It takes the entire team MD RN Physical Therapy to prevent Preventable VTE events 32

33 Questions? 33

34 Polling Question #3 How well did this Learning activity meet the stated objectives? 1. Excellent 2. Good 3. Fair 4. Poor 5. N/A 34

35 Polling Question #4 Amount of useful information and ideas provided: 1. Excellent 2. Good 3. Fair 4. Poor 5. N/A 35

36 Polling Question #5 Usefulness to my hospital of the information and ideas provided: 1. Excellent 2. Good 3. Fair 4. Poor 5. Not Applicable 36

37 Polling Question #6 Chance that the information and ideas provided will improve my effectiveness and results: 1. Excellent 2. Good 3. Fair 4. Poor 5. N/A 37

38 Announcements Schedule Coaching Calls Review Culture of Safety Survey Upcoming Webinar December 20: Health Literacy through Teachback VHHA Patient Safety Summit January 31-February 1 Pre-Summit NoCVA HEN Learning Session January 30th 38

39 Contact Information Jan Mangun, MT(ASCP), MSA, CPHRM Executive Directive, Quality & Patient Safety Debbie Roddenberry Assistant Director