DVT Prophylaxis and Pulmonary Embolism

1. DVT Prophylaxis and Pulmonary Embolism Karen Ruffin RN, MSN Ed.

2. Frequency in the US • Up to 2 million people are affected annually by Venous Thromboembolism(VTE). • Of those 2 million people it is estimated that 300,000 of them will develop and die from a Pulmonary Embolism (PE). • The highest incidence of PE is with hospitalized patients. • Autopsy shows that as many as 60% of patients dying in the hospital have had a PE, but the diagnosis is being missed 70% of the time. According to: Center for Disease Control (CDC), Department of Health and Human Services, Food and Drug Administration (FDA), The Surgeon General

3. Percentage if at risk for Development of a VTE • All hospitalized patients, depending on acuity, have between a 10%-48% of developing a VTE • Med-Surg patients placed on bed rest for a week (10%-13%). • Patients in the MICU (29%-33%). • Patients with Pulmonary Disease on bed rest for 3 or more days (20%-26%). • Patients in the CCU with an MI (27%-33%). • Patients who are asymptomatic after a CABG (48%). Feied, C.F. & Handler, J.A., (2008)

4. Mortality and Morbidity • Approximately 10% of the patients with an acute PE will die with in the first 60 minutes. • 1/3 of those who live, the condition is diagnosed and treated. • 2/3 of the remaining patients go undiagnosed. • Deaths that are a result of VTE/PE were shown to be the most common cause of preventable hospital deaths THAT IS HUGE! According to: Center for Disease Control (CDC), Department of Health and Human Services Food and Drug Administration (FDA), The Surgeon General

5. Mortality and Morbidity • Race- Subtle population differences may exist, but the incidence is high in all racial groups. • Sex- Women only when they are pregnant. • Age- Although the frequency for developing a PE increases with age, age alone is not an independent risk factor. It has more to do with co-morbidities.

6. Virchow’s Triad • Vessel Damage • Vascular Constriction • Blood Viscosity

7. Vessel Damage • Endothelial cells allow blood to flow with ease through vessels. • Factor VIII or Willibrand’s Factor • Conditions/lifestyles that damage vessel walls: • Past VTE - Pressure Ulcers • Smoking - Cellulites • High Cholesterol • Varicose Veins

8. Vascular Constriction • Trauma • Surgery • Insertion of central line • Varicose Veins • Restricted Mobility • Sepsis • Induction • MI • HF • Stroke Any external force that cause damage to the vascular system can cause slow blood flow

9. Blood Viscosity • Dehydrating • Birth Control Pills • High estrogen states • Pregnancy • Postpartum • Cancer • Sepsis • Blood transfusions • Obesity • IBS • Hematologic Disorders • Elevated Blood Sugar • Platelet Aggregation

10. Physiology of Clotting

12. What is the difference between a thrombus and an emboli? • A thrombus is a clot that is stationary and a emboli is a thrombus that has broken off and is traveling.

13. Most Common Cause of a PE • 90% are thrombi dislodged from deep veins in the calf. • Some originate in the pelvis, particularly in pregnant women. • Fat embolus occur when long bones are broken (this is rare).

14. What is a Pulmonary Embolism (PE)? • Occlusion of a portion of the pulmonary vascular bed by an embolism. They can be a: • Thrombus (Blood Clot) • Tissue Fragment • Lipids (Fat) • Air Bubble

15. Pathophysiology • Once the embolus is released into the blood stream they are distributed in: • 65% of the time both lungs • 25% of the time right lung ▪10% of the time left lung ▪ Lower lobes are 4 times more often upper lobes.

16. Pathophysiology • Massive Occlusion- an embolus that occludes a major portion of the pulmonary circulation. • Embolus with Infarction- An embolus that is large enough to cause an infarction (death) of a portion of lung tissue • Embolus without Infarction- Not sever enough to cause permanent lung injury. • Multiple Pulmonary Emboli- This can be chronic or recurrent.

17. Previous episode of thromboembolism Prolonged immobility Cancer Obesity Pregnancy Oral estrogen Fever Atrial fibrillation CHF, Shock Varicose veins Over 60 y/o Hematologic disorders Trauma Central Lines Dehydration Hypovolemia Surgical Patients Risk Factors for DVT and PE

18. Prophylaxis Strategies • The evidence based practice guidelines published by the ACCP in June 2008 incorporated data obtained from a comprehensive literature review of the most recent studies available. • The recommendations are broken up in to different categories from general patient populations to specific groups and conditions. American College of Chest Physicians, (2008)

19. Understanding the Different Recommendation Categories • Grade 1: Benefits outweigh risk • Grade 2: Less certain about the magnitude of benefits versus risk • Grade A: High quality evidence • Grade B: Moderate quality evidence • Grade C: Low quality evidence American College of Chest Physicians, (2008)

20. General Patient Population • Every hospital should have a formal strategy for addressing VTE prophylaxis (Grade 1A) • Mechanical methods of thromboprophylaxis should be used primarily in patients who have a high risk of bleeding (Grade 1A) • It is recommended against the use of aspirin alone as thromboprophylaxis for VTE for any group of patients (Grade 1A) American College of Chest Physicians, (2008)

21. What about patients w/ a PICC line?????? • We are a seeing and increased incidence of DVT in patients with PICC lines. • How can we assess for it?

22. Clinical Manifestation of PE • Massive Occlusion- Profound shock, hypotension, tachycardia, pulmonary hypertension, and chest pain. • Embolus with Infarction- Pleural pain, pleural friction rub, pleural effusion, hemoptysis, fever, and leukocytosis. • Recurrent PE- Occur in individuals who have had a history of previous emboli.

23. Applying the Nursing Process • Assessment • Diagnosis • Planning • Intervention • Evaluation

24. Homon’s sign H&P Cough Sudden onset of SOB Agitation Lightheadness Fainting Dizziness Sweating Anxiety Rapid Breathing Tachycardia Air Hunger Assessment and Symptoms

25. What are your nursing diagnosis going to be??? Tell me your long and short term goals.

26. Arterial Blood Gases EKG Echocardiogram Chest x-ray VQ scan Spiral CT scan Pulmonary Angiogram Pt, ptt, INR D-DImer Split Fibrinogen MRA Diagnostics

27. Remember to always have: Assessment Action Psychosocial Education For every goal! What are your Interventions for your stated goals?

28. Treatment • Supportive • Filters • Anticoagulants/Thrombolytics • Heparin • Coumadin • Streptokinase • Retavase • TPA

29. So what will we evaluate and why?

30. Cost of Prevention vs. Treatment???? • V/Q scan- $1500 • ICU bed $9000 day • Arterial Angiogram- $3200 • Many other realted cost????? • Sequential stockings- $10 day • Heparin subq- pennies a day • Lovenoxsubq $15 a day

31. Prevention is KEY • Intermittent Pneumatic Stockings • SCD • Teds • Early Ambulation • Low Dose Anticoagulation • Heprin • Lovenox • Arixtra

32. So, what does all of this mean to us?

33. Assessment and Documentation • We must assess if a patient is at risk for the development of a VTE • Document that assessment • Communicate with the health care team that the patient is at risk for a VTE. • Document that communication • Education, Education, Education

34. Why are all those steps important???? • The Joint Commission and the Centers for Medicare and Medicaid have implemented VTE quality measures for surgical patients which include the Surgical Care Improvement Project (SCIP 1 & SCIP 2). • SCIP 1 evaluates if patients were identified as being at risk, was prophylaxis ordered appropriately. • SCIP 2 examines if prophylaxis was actually received by patient. Surgical types include: ortho, gyn, urological, elective spine, intracraneal . Appropriate prophylaxis includes: LDUFH, Fundaparinux, LMWH, warfarin

35. Why are all those steps important???? • The CMS has created guidelines on payment for service for healthcare providers that use evidence based practice to promote the best possible outcomes for its customers.

36. In 2005, section 5001(c) of the Deficit Reduction Act of 2005 (DRA) authorized the Secretary of the Department of Health and Human Services to select conditions that:  • (1) are high cost, high volume, or both; (2) are identified through ICD-9-CM coding as complicating conditions (CCs) or major complicating conditions (MCCs) that, when present as secondary diagnoses on claims, result in a higher-paying MS-DRG; and (3) are reasonably preventable through the application of evidence-based guidelines.

37. So what does that mean to the bedside nurse? • We must encourage all healthcare members to follow best practices as outline by creditable bodies such as the ACCP. • Our role in assisting with reimbursement for care provided is to appropriately assess our patients and determine who is at risk for VTE/PE. • Next we must communicate this information with the physicians. • Once orders are receive for thromboprophylaxis we should ensure that treatment is delivered as soon as possible or within 2 to 3 hours of receiving the orders.

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

39. Case Studies • 37y/o women presented to the ER 18 days s/p laparotomy for lyses of adhesions. • Symptoms- CP, SOB, lightheadness, tachycardia. • She was seen by an NP and not by an MD. CBC, Cardiac Enzymes, and Chem 7 ordered and were normal. Pt was sent home and told to follow up with her primary in two days. • Pt. suffered a nonfatal PE that night. She was awarded $1,000,000.00

40. Case Study • Nurse was to D/C a pt. home. She noted a large reddened, raised, warm area on the pt. right ankle. The nurse documented it, but did not notify the physician. • The pt. suffered a fatal PE two days later. A claim was filed against the nurse and was settled for $4,000,000.00.

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

42. -American College of Chest Physicians, (2008). Antithrombotic and Thrombolytic Therapy: American College Of Chest Physicians Evidence –Based Clinical Practice Guidelines. 8th Edition. Volume 133/number 6 (Suppl) pages 67s-968s.-Center for Disease Control, (2008). Are you at risk for deep vein thrombosis? Retrieved from http://www.cdc.gov/Features/Thrombosis on December 12, 2008.-Center for Medicare and Medicaid Services, (2008). CMS improves patient safety for Medicare and Medicaid by addressing never events., CMS Manual System.-Feied, C.F. & Handler, J.A., (2008). Pulmonary Embolism. Retrieved from eMedicine.com on December 12, 2008.-Galson, S.K., (2008) The Surgeon General calls to action to prevent deep vein thrombosis. US Department of Health and Human Services Office of the Surgeon General. Retrieved from http://www.surgeongeneral.gov on December 12, 2008.-National Institute for Health, (2007). What is a Deep Vein Thrombosis? Retrieved from http://www.nhlbi.nih.gov/health/dci/Diseases/Dvt on December 12, 2008.-Sanofi-Aventis, (2008). The Coalition to Prevent Deep-Vein Thrombosis. Retrieve from, http://www.preventdvt.org on December 12, 2008.-Sumpio, B.E., Riley, J.T, Dardik, A. (2002). Cells in focus: endothelial cell. Department of Surgery, Yale University School of Medicine. Retrieve from http://www.ncbi.nlm.nih.gov on December 12, 2008.

43. Now we will do an Evolve case study!